Full text of "Primary malignant growths of the lungs and bronchi; a pathological and clinical study"

See other formats

COLUMBIA LIBRARIES OFFSITE

HEALTH SCIENCES STANDARD

HX640661 50
RD667 Ad5 Primary malignant gr

RECAP

i i ! i 1 I i

:^ ;ii !i 1 1 , !

i 1 1=1
Ml! i 1 ! 1 1

lUiuliiluinluiluiUini

IBBlHiB

lil!i'>n!!i!il!!!liil!!lll

1^-bGGl

Ad^

Columbia SBmtier^ttp
mtljeCitpotBrwgork

CoUege of S^fiv^itims anb ^urgcong

Hibrarp

. J. C- .

'A,^^

^^/cML^U^ ^/' //

PRIMARY
MALIGNANT GROWTHS

OF THE

LUNGS AND BRONCHI

Digitized by the Internet Archive

in 2010 with funding from

Open Knowledge Commons

http://www.archive.org/details/primarymalignantOOadle

PRIMAEY
MALIGNANT GROWTHS

OF THE

LUNGS AND BRONCHI

A PATHOLOGICAL
AND CLINICAL STUDY

I. ABLER, A.M., M.D.,

Professor Emeritus at the New York Polyclinic, Consulting
Physician to the German, Beth-Israel, Har Moriah,
and Peoples Hospitals, and Montefiore
Home and Hospital

'Oportet omnia signa contemplari'

LONGMANS, GREEN, AND CO.

FOURTH AVENUE & 30TH STREET, NEW YORK

LONDON, BOMBAY, AND CALCUTTA

1912

All Bights Reserved

THE'PLIMPTON'PRESS

[ W • D • o]
NORWOOD. MASS'U'S -A

MY OLD-TIME TEACHER AND FRIEND

HIS EXCELLENCY

GEH. RAT. PROF. DR. JULIUS ARNOLD

IN HEIDELBERG
IN GRATITUDE AND AFFECTION

PEEFACE

T HAD intended that this little monograph on lung
■^ tumors should be handed to Professor Arnold on the
occasion of the festival held August 19, 1905, to celebrate the
seventieth birthday of the master. The plan as originally
conceived could not be carried out, but it is hoped that the
delay in bringing out the work may not have been alto-
gether valueless in that it made possible a considerable
increase in the volume of the material. Great thanks are
due to my friends and assistants. Dr. O. Hensel and Dr.
O. F. Krehbiel, for their indispensable aid in collecting and
sifting the material. I am greatly indebted, as well, to
Miss Laura E. Smith, of the Library of the New York Acad-
emy of Medicine. I wish also to express my sincere
thanks to Dr. H. S. Tienken for her untiring interest, un-
selfish devotion, and technical skill in the proper recording
and tabulating of the material, and to Dr. A. L. Garbat
and to Miss F. H. Fiske for the strenuous work of seeing
it through the press. Finally, I would acknowledge my
debt to Dr. F. S. Mandlebaum of New York and to Professor
S. B. Wolbach of Boston for the very beautiful photographs
used here as illustrations.

The author dares to hope for kindly criticism and some
renewed interest in the subject.

I. ADLER

New York, Christmas, 1911

vii

CONTENTS

CHAPTER PAGE

I. Introductory 3

Mostly statistical,

II. Introductory {Continued) 13

Remarks on Plan oj Monograph.

III. A Few Historical Notes 16

The Precancerous Influences.

IV. Precancerous Influences (Continued) .... 26

Etiology of Malignant Tumors — Relation of Tuberculosis to
Lung Tumors.

V. Pathology 39

Gross Appearance of Lung Tumors — A Minute Study of
Sarcoma and Carcinoma.

VI. Pathology (Continued) 55

Histogenesis of Carcinoma — Endothelioma.

VII. Pathology (Continued) 62

Metaplctsia.

VIII. Clinical 68

IX. Clinical (Continued) , . 86

Appendices ■ - . 110

TABLES
I. Carcinoma , . 114

II. Sarcoma , . 240

III. Doubtful 278

IV. Miscellaneous 314

LIST OF ILLUSTRATIONS

[The Plates Numbered I to XVI are at the End op the Volume]

Frontispiece. — Section of lung, showing a large tumor originating from
the root and destroying the greater part of lung. Communicating cavities
and tumor nodules of varying sizes. That portion of lung not infiltrated
with tumor, compressed and pushed backward towards the spine.

(From a drawing by H. Becker.)

Plate I. — Transverse section across an infiltrating tumor and adjoining lung.
Tumor area sharply defined against lung tissue. Infiltration so dense and
complete that only a few vessels and slightly dilated bronchi are visible as
remnants of normal structure. (From a drawing by H. Becker.)

Plate II. — Shows destruction of almost entire lung. Pulmonary tissue almost
completely replaced by tumor. (From a drawing by H. Becker.)

Plate III. — Section of medullary carcinoma illustrating the occasional impossi-
bihty of differentiating between carcinoma and sarcoma.

Plate IV. — Same section as preceding, photographed with high power, ex-
hibiting the same indeterminate character.

Plate V. — Section from another portion of the same tumor as shown in Plate
IV. In structure and in character of cells plainly suggesting carcinoma.

Plate VI. — Shows section through kidney from same case. An incipient
metastatic deposit, consisting of a few genuine epithelial cells just entering
Bowman's Capsule, is shown.

Plate VII. — Typical picture of ordinary form of carcinoma. A large alveole
is seen, directly injecting a lymph- vessel with cancerous cells.

Plate VIII. — Rapidly proUferating carcinoma, suggesting glandular type.
Very little stroma between the alveoles, which latter contain mostly flat
and cuboidal epithelial cells.

Plate IX. — Same form of carcinoma. Smaller and more plexiform alveolar
structure, more voluminous stroma, injection of lymph-spaces and lymph-
vessels from alveoles.

Plate X. — Cancroid with characteristic homy epithelial nests.

xii LIST OF ILLUSTRATIONS

Plate XI. — Cylindrical-celled carcinoma, the epithelium not ciliated. Alveolar
structm-e, alveoles varying largely in size. Much mucoid degeneration.
Origin from bronchial mucous glands.

Plate XII. — Same type of tumor. To the right, dilated bronchus. In middle
bronchial mucous glands, transition to carcinomatous alveoles plainly seen.

Plate XIII. — Similar type of timior. Shows partial destruction of bronchial
cartilage and various transitions from normal bronchial mucous glands to
cancerous alveoles.

Plate XIV. — Cylindrical-celled carcinoma. Suggestions of alveolar structure.
Striking papillary arrangement.

Plate XV. — Besides alveolar structure, shows marked participation of lymph-
vessels and spaces in the cancerous proliferation.

Plate XVI. — Shows practically only affection of lymphatic apparatus. Both
this plate and the one preceding represent sections taken from tumors which
in other localizations show typical carcinomatous structure.

PEIMAEY MALIGNANT GEOWTHS
OF THE LUNG

CHAPTER I
INTRODUCTORY

IS it worth while to write a monograph on the subject of
primary mahgnant tmnors of the Imig? In the com'se of
the last two centuries an ever-increasing hteratiu-e has accu-
mulated around this subject. But this Hterature is without
correlation, much of it buried in dissertations and other out-
of-the-way places, and, with but a few notable exceptions, no
attempt has been made to study the subject as a whole, either
the pathological or the cUnical aspect having been emphasized
at the expense of the other, according to the special predilec-
tion of the author. On one point, however, there is nearly
complete consensus of opinion, and that is that primary mahg-
nant neoplasms of the lungs are among the rarest forms of
disease. This latter opinion of the extreme rarity of primary
timaors has persisted for centuries. Within the last few
decades attempts have been made to combat this dogma, but
even now the overwhelming majority of medical practitioners
rarely, if ever, think of a diagnosis of tumor of the lungs, and
the ubiquitous tuberculosis, with its multiform clinical appear-
ances and its plastic adaptation to all ages and all conditions
of mankind, is ever ready to fxmiish, to all but a very few,
a comfortable and satisfactory diagnosis.

Most textbooks hardly notice lung tumors, and if they give
the subject any consideration it is, for the most part, insuf-
ficient. Thus the well-known and still authoritative textbook
on Diseases of the Lungs and Pleurae, including Tuberculosis
and Mediastinal Growths, by Sk R. Douglas Powell and

4 PRIMARY MALIGNANT GROWTHS OF THE LUNG

P. Horton-Smith Hartley (5th Edition, 1911), while treating
at length of thoracic tumors and of mediastinal tumors, etc.,
has scarcely more than one page to cover the entire subject of
carcinoma and sarcoma of the lungs. The excellent book of
A. Frankel ^ and the admirable chapters on carcinoma of the
lungs in the latest edition of Wolff, ^ as well as a few other
publications,^ attempt a more comprehensive presentation of
this type of tumor, but they seldom get into the hands
of the medical public at large, and so it happens that the
general practitioner is not in a position to diagnosticate a
primary lung tumor as often as might be, and the belief in
the extreme rarity of these cases is still maintained. To add
to these difficulties, even the diagnoses made on the autopsy
table are not always reliable. There are still careless or insuf-
ficiently trained persons called upon to do this rather dehcate
work. It may happen also that the most careful and search-
ing autopsy will not furnish the true diagnosis until a thorough
microscopical examination has been made. Take for example
the case of Walter Kretschmar; * also of Morelli,^ This
latter case is remarkable for a number of unusual features:
the youth of the patient, — a female aged twenty-eight, —
the sudden onset after cold, with fever and cough, the clinical
symptoms of a pneumonic consoUdation in right base with
pleural effusion and endocarditis. The sputum showed diplo-
cocci. On autopsy both lungs showed white nodules, corre-
sponding to blood vessels, and connective tissue strands not
infrequently seen after pneumonic processes. No tumor
could be recognized, and only upon microscopic examination
were nests of epithelial cells discovered in the lymph spaces

1 Spezielle Pathologie u. Therapie der Lungenkrankheiten, 1904.

2 Die Lehre von der Krebskrankheit, Vol. II, pp. 803 ff., Jena, 1911.

' Credit must be given here to Alfred v. Sokolowski, Klinik der Brustkrank-
heiten, Vol. I, Berlin, 1906, and his study of primary malignant and non-malig-
nant neoplasms of the bronchi and lungs. He seems to consider bronchial
carcinoma extremely rare, — much more rare than primary tumors of the lung.
He has a chapter of about fifteen pages devoted to lung tumors, citing several
cases of his own experience. He goes rather quickly over the pathology and
diagnosis of carcinoma and in the same way hurries over sarcoma without
bringing in anything notably new.

^ tjber das primare Bronchial- imd Lungencarcinom, Diss. Leipzig, 1904.

B Table I, No. 201.

INTRODUCTORY 5

of the fibrous tissue, and epithelial clusters in the alveoles and
in the alveolar septa.

Furthermore, v. Hansemann ^ relates that in his experi-
ence at the Friedrichshain Hospital there were 711 carcino-
mata out of 7790 autopsies, of which 156, or 21.94%,
were not diagnosticated during life, not even as tumors.
Among these 156 cases there were sixteen bronchial and pul-
monary tumors. Is it not somewhat humiliating to realize
that the difficulties of diagnosis are still so great as to pre-
vent the best and most experienced medical men, with all
the advantages of a large hospital, from discovering almost
one-fifth of all the carcinomata that come before them? If
these figures hold good generally, about one-fifth more car-
cinoma cases should be added to our ordinary statistics.
Another important addition to the difficulties to be contended
with lies in the fact that in many countries, as for example
our own, justly claiming an advanced stage of civilization,
the overwhelmingly great majority of the dead are not sub-
jected to any post-mortem examination, and the death
certificates on which burial permits are officially given are
often ludicrously insufficient. For this reason the United
States Census is entirely useless for our purposes. As an
example of the misleading diagnoses and insufficient observa-
tion which hamper one in getting up the literature of this
subject, look up the following: Two Cases of Melanotic
Tumors in the Lungs.^ Reliable autopsies, in the majority
of cases, there are not, and many autopsy notes that have
been recorded are so insufficient in their data and descriptions
that a conclusive opinion on the case cannot be formed. The
same applies to the clinical notes. It is therefore impossible
to say, from the figures given by the United States Census
concerning causes of death, how many persons mentioned
as having died from tuberculosis, pneumonia, or kindred
diseases, may not really have died from lung tumors.

Considering all this, it seems primarily necessary to

^ Riechelmann, Eine Krebsstatistik vom pathologisch-anatomischen Stand-
punkt, Berl. Klin. Woch., 1902, N. 31 and 32, pp. 728 ff.
2 Journal A. M. A., 1888, p. 53.

6 PRIMARY MALIGNANT GROWTHS OF THE LUNG

procure enlightenment on the question : Are malignant tumors
of the lung as rare as has been supposed? And if they are not
so rare, is their more frequent occurrence due to a supposed
general increase in the incidence of malignant growths?
WilUams/ an enthusiastic exponent of the increase of car-
cinoma as a whole and the corresponding decrease of
tuberculosis, supports his view with a great mass of statis-
tical figures, of which some few are quoted here.

1840

Incidence in England and Wales
1905

2786, a proportion to total
number of deaths of
1:129, or 177 per
million living.

30221, a proportion to total
number of deaths of
1:17, or 885 per
million living.

As to Newsholme's contention ^ that the registered increase is
only apparent, being actually due to improved methods of
diagnosis and death certification, WiUiams's answer is that
(1) the uniformity in increase is too marked to be due to im-
proved diagnosis, and (2) the very improvements cited have
also caused subtractions from the cancer total, since many
diseases formerly erroneously called cancer are now given
their true names. Nencki is quoted in this connection * as
giving the increase in cancer death-rate in Switzerland from
114 in 1889 to 132 in 1898 (per 100,000 living). WilHams
gives the following figures for other countries:

Deaths fbom Cancer

Paris, France 1865 84

1900 120

Germany 1872 59

1900 71

Berlin 1870-1882 57

1899 109

Italy 1880 21

1905 58

United States

(per 100,000 Uving)

1850....

.... 9

1900 . . .

...43

New York

1864 . . .

...32

1900 . . .

...63

Boston

1863 . . .

...28

1903 . . .

...85

New Orleans

1864 . . .

...15

1903 . . .

...82

San Francisco

1856 . . .

...16

1900 . . .

...112

* Natural History of Cancer, New York, 1908.
» Proceedings of the Royal Society, 1893, Vol. LFV, p. 209.
' Die Frequenz und Verteilung des Krebses in der Schweiz, etc., Zeitschr.
f. schw. Statistik, 1900, Vol. II, p. 332.

INTRODUCTORY 7

Other important statistical work to be consulted is that of
Robert Behla/ the great standard work, in four volumes,
of Juliusburger,2 and the work of Newsholme.^ Looking
carefully over these statistics, it is the writer's opinion that
the statistics of Williams, as well as all statistical material
thus far collected, with a great deal of care and labor, have
not succeeded in proving conclusively that there is a real
increase in the incidence of cancer and a corresponding
decrease in the incidence of tuberculosis. The fact may
turn out to be so, but at this writing can by no means
be considered as proven. The only figiu-es which in the
course of time will give us the means of definitely solving
problems such as this will be those obtained from hospitals,
where the material is more uniform, where the best modem
methods of observation and diagnosis are applied, and where
finally the autopsies and microscopical examinations are done
with the utmost care. Reports of life insurance officers, statis-
tics taken from books of registrars and recorders, where only
the causes of death are mentioned, cannot be effectively
utilized.

It has been shown, especially by the researches of Behla
just quoted, that some sort of influence of occupation or
trade may possibly be considered a factor in the incidence
of carcinoma. If so, this factor is of very slight significance
and may, at least for the study of lung tumors, be entirely
disregarded.

It is the conviction of the writer, and he shares this belief
with many others, — the mention of whose names and criti-
cism of whose work need not be entered upon here, — that
there is no absolute increase in the incidence of carcinoma.
Nevertheless, the incidence of malignant neoplasms of the
lungs seems to show a decided increase. It has been stated
that statistical research in this direction is beset with many
difficulties. It may be hoped that in the course of a few

^ Krebs und Tuberkulose in beruflicher Beziehung vom Standpunkte der
vergleichenden internationalen Statistik, Berlin, 1910.

^ Die Krankheits- und Sterblichkeitsverhaltnisse in der Ortskrankenkasse
fiir Leipzig und Umgegend.

' The Statistics of Cancer, The Practitioner, April, 1899.

8 PRIMARY MALIGNANT GROWTHS OF THE LUNG

years accurate and reliable figures will be available. In the
meantime, however, the following table, founded on figures
collected by Karrenstein ^ and considerably amended and
enlarged, will at least serve to show, not the causes, but the
fact of the apparent increase. It is very significant that in

Primart Carcinoma of the Lungs and Bronchi

VII

Time

Place

% of all

Total

% of aU

Total

Author

Carci-

No.

Autop-

No. of

noma

Carci-
noma
Cases

sies

Autop-
sies

1. 1852-67

Stadtkrankenhaus,
Dresden

0.91

8716

Reinhardt^

2. 1852-1908

Patholog. Institut,
Wurzburg

15 or
0.93

1607

Fockler '

3. 1854-85

Stadtkrankenhaus,
Mtinchen

8 cases

0.065

12307

Fuchs*

4. 1870-88

Patholog. Institut der
Universit . Kolozsvar

145

Buday ^

5. 1872-89

Patholog. Institut,
Bern

2
0.42

474

0.059

3363

C. Miillers

6. 1872-98

Reichsgesundheits-
amt, Hamburg

84
0.70

11930

0.02

336486

Reiche'

7. 1873-87

Patholog. Institut,
Kiel

Danielsen ^

8. 1877-84

Stadtkrankenhaus,
Dresden

9 cases

0.22

4712

Wolfs

9. 1881-94

Patholog. Institut,
Breslau

1.83

870

9246

Passler^"

10. 1885-94

Stadtkrankenhaus,
Dresden

cases

0.43

7728

Wolf 11

1 Charit^-Annalen, Berlin, 1908.

2 Reinhardt, Der primare Lungenkrebs, Arch. f. Heilkunde, XIX, 1878.-2.
^ Fockler, Krebsstatistik nach den Befunden des patholog. Instituts zu

Wurzburg, Diss. Wiirzburg, 1909.

^ Fiichs, Beitr. zur Kenntnis der Geschwiilstbildungen in der Lunge, Diss.
Miinchen, 1886.

^ Buday, Statistik der im patholog. -anatom. Institut der Universitat Koloz-
svar usw. Zeitschr. f. Krebsforschung, Vol. VI, S. 7.

' Miiller, C, Beitrag zur Statistik der malignen Tumoren, Diss. Bern, 1890.

^ Reiche, Beitrage zur Statistik des Carcinoms, Deut. Med. Woch., 1900,
N. 7, p. 120 ff.

8 Danielsen, Quoted from Schlereth, 2 FaUe von primarem Lungenkrebs,
Diss. Kiel, 1888.

9 Wolf, Fortschritte der Medizin, 1895.
10 Passler, s. S. 315, No. 5.

" Wolf, loc. cit.

INTRODLXTORY 9

Primary Carcinoma of the Lungs and Bronchi — Continued

III

VII

Time

Place

%■ of all

Total

%of aU

Total

Author

Carci-

No.

Autop-

No. of

noma

Carci-
noma
Cases

sies

Autop-
sies

11. 1886-96

Krankenhaus,
Munchen

9
1.2

706

0.10

8727

Periitzi

12. 1887-1906

Patholog. Institut,
Wien

0.17

40000

Haberfeld2

13. 1888-97

Patholog. Institut,
Greifswald

1.78

Kaminski^

14. 1888-1905

Patholog. Institut,
Universit. Kolozsvar

4.5

221

Buday *

15. 1895-1901

Friedrichshain, Berlin

711

7790

Riechelmann ^

16. 1899-1903

Patholog. Lab.
Lubarsch, Posen

3
1.2

159

0.17

1741

Sehrte

17. Vor 1900

Patholog. Institut
am Urban-BerUn

100

0.4

Feilchenfeldt^

18. 1899-1904

Patholog. Institut
am Urban-Berlin

0.6

Benda^

19. Zeitraum

Patholog. Institut,

Rieck 9

V. 10 Jahr.

Univ. Miinchen

1.92

20.

6
1.3

447

Lebertio

21. 1900

Patholog. Institut,
Charit^Berlin

2.91

3 cases

103

0.23

1300

Karrenstein i^

22. 1900-05

Urban-Berlin

31
0.61

496

0.6

5002

Redlichi2

23. 1901

Patholog. Institut,
Charity-Berlin

8.86
7 cases

0.53

1310

Karrenstein"

^ Perutz, Zur Histogenesis des primaren Lungenkarzinoms, Diss. Miinchen,
1897.

^Haberfeld, Carcinom des Magens, der Gallenblase und Bronchien.
Z'tschrift f. Krebsforsch., Vol. VII, I. Fasc, p. 204.

3 Kaminski, s. S. 315, No. 6.

* Buday, loc. cit.

^ Riechelmann, Eine Krebsstatistik von path.-anatom. Standpunkt, Berl.
klin. Woch., 1902, N. 31 and 32, pp. 728 ff.

^ Sehrt, Beitrage zur Kenntnis des primaren Lungenkarzinoms, Diss. Leip-
zig, 1904.

7 Feilchenfeldt, Quoted from Benda, Deut. Med. Woch., 1904, S. 1454.
Beitrage zur Statistik und Kasuistik des Karzinoms, Diss. Leipzig, 1901 (after
Redlich).

8 Benda, loc. cit., S. 1453.

5 Rieck, Krebsstathstik nach den Befunden des patholog. Instituts zu
Miinchen, Diss. Munchen, 1904.

1" Lebert, Traits pratique des Maladies cancereuses.

" Karrenstein, Charite-Annalen, XXXII Jahrg., Berlin, 1908.

12 Redlich, Die Sektions-Statistik des Carcinoms, etc., am Stadt-Kranken-
haus am Urban, 1900-1905, Diss. Berlin, 1907.

10 PRIMARY MALIGNANT GROWTHS OF THE LUNG

Primary Carcinoma of the Lungs and Bronchi — Continued

III

VII

Time

Place

% of all

Total

% of aU

Total

Author

Carci-

No.

Autop-

No. of

noma

Carci-
noma
Cases

sies

Autop-
sies

24. 1902

Patholog. Institut,
Charity-Berlin

3.23
3 cases

0.31

999

Karrenstein^

25. 1903

Patholog. Institut,
Charite-BerUn

3.19
3 cases

0.24

1272

Karrenstein ^

26. 1904

Patholog. Institut,
Charite-Berlin

2.67
4 cases

150

0.28

1399

Karrenstein ^

27. 1905

Patholog. Institut,
Charite-Berlin

0.71
1 case

140

0.08

1313

Karrenstein^

28. 1906

Patholog. Institut,
Charite-Berlin

4.84
6 cases

124

0.46

1319

Karrenstein^

29. 1906-08

Krankenhaus, r. d. I.,
Manchen

174

0.18

945

Forstner^

30. 1907

Patholog. Institut,
Charite-Berlin

3.31

5 cases

151

0.37

1360

Karrenstein 1

31. 1908

Stadtkrankanstalten,
Hamburg

11
1.2

920

Korber'

32. 1908-09

Patholog. Institut
Krankenhaus,
Miinchen

1.8

212

0.29

1371

Nobiling^

33.

Basel

1.76

Kauf mann ^

34. 1910-11

Charity- Annalen,
Berlin

0.76

141

0.05

185

Orth6

1900 the Pathological Institute of the Charite in Berlin
recorded only three cases of lung tumor, while in 1906 and
1907 five and six cases respectively, were recorded. It is
more significant still when the reports of the Pathological
Institute of Kolozsvar from 1870 to 1880 and from 1888 to
1905 respectively, are compared. It is to be remembered that
this table is made up mainly from records of pathological
laboratories of fairly high standing.

There seems hardly room for doubt that the increase in
the percentage of lung tumors is to be attributed mainly to

^ Karrenstein, Charitl-Annalen, XXXII Jahrg., Berlin, 1908.

2 Forstner, tjber maligne Tumoren, Diss. Miinchen, 1908.

' Korber, Die Ergebnisse der Hamburgischen Krebsforschung im Jahre
1908. Mitt. Hamburgischen Staatskrankenanstalten, Vol. IX, Supp., 1908.

* Nobihng, Z'tschrift f . Krebsforsch. patholog. Institut Krankenhaus,
Miinchen, r. d. I., 1908-1909.

' Kaufmann, Lehrbuch der Spec. Path. Anatomie, Basel, 1909.

6 Orth, Charit6-Annalen, Berlin, XXXV Jahrg., 1911.

INTRODUCTORY 11

the increased attention paid to these types of tumor and the
greater care and more extensive microscopic investigation
with which autopsies are carried out at present. As early
as 1837, Stokes ^ had aheady remarked that in his experience
lung tumors are by no means as rare, either in England or in
Ireland, as was generally assumed, and Boyd ^ even goes so
far as to assert that primary cancer is more frequent in lungs
than secondary cancer, an assertion which he explains as
follows : ''A case of maUgnant deposit in the bronchial glands,
infiltrating the lung, ending in ulceration and the formation
of cavities, is frequently set down as one of hopeless phthisis,
a post-mortem on which would be of no interest, and all
record of the frequency of the disease is in consequence
entirely lost." This utterance of Boyd's is probably some-
what of an exaggeration, for while it has just been shown
that the behef in the extreme rarity of lung tumors, a lusus
naturae, as it were, can no longer be maintained, it must be
conceded that these tumors belong to the class of rarer
neoplasms and their incidence is out of all proportion to the
frequency of occurrence of other malignant neoplasms, as for
example of the female breast or the stomach.

Seeing, thus, that lung tumors are to be reckoned with more
often than was formerly believed, it is to be expected that
nimierous problems, both pathological and clinical, will
present themselves. Besides these problems of purely theo-
retical interest to the pathologist and the clinician, there is
the great importance to the patient of a correct diagnosis.
It cannot be a matter of indifference to the unfortunate
sufferer whether his case be diagnosticated as tuberculosis
or as tumor. If tuberculosis, he will be sent from one climate
and one sanitarium to another, he and his family possibly
deluded with false hopes, until finally secondary symptoms
have cleared up the case and death has brought relief. The
grave prognosis which is an integral part of the diagnosis of
tumor may be of paramount importance to the patient as well
as to his relatives. At all events, so much is certain, that if

1 Diseases of the Chest, London, 1837.

2 Table I, No. 46.

12 PRIMARY MALIGNANT GROWTHS OF THE LUNG

the diagnosis of lung tumors is to be developed so as to render
it more precise, and if any reasonable attempt is to be made to
convert the present desperate prognosis into one less hopeless,
this great result can only be achieved if the internist shall
work hand in hand and shoulder to shoulder with the surgeon.
The internist must be able to furnish as early and as accurate
a diagnosis as possible, so that the surgeon under favorable
conditions may develop his technique as early as possible.
With these few introductory words, the initial question, it is
dared to hope, is answered affirmatively.

CHAPTER II

IN TROD UCTOR Y {Continued)

IN undertaking to write this monograph, it is proposed to
present the subject and the problems connected therewith
in as comprehensive and at the same time as concise a manner
as possible. Not only carcinoma, but the other malignant
tumors of the lung are to be presented, both from a broad
pathological, as well as from a clinical point of view.

As the first step toward the accomplishment of this end,
it was found necessary to collect a very large material from
the literature. Thus far, but comparatively few cases had
been picked up. Passler,^ after much sifting, managed to
collect about seventy-four cases of undoubted primary car-
cinoma of the lungs. This was in 1896, just fifteen years
ago. The latest publication ^ casually remarks that about
one hundred cases may now be found in literature. The
difficulties of collecting cases in point have already been
hinted at. It is extremely trying to delve into all sorts of
doctor-dissertations, obscure and forgotten publications of
all kinds and in all languages, to be frequently rewarded by
finding that, after all, the case is secondary, or is not a case in
point at all, or that no autopsy was made, or that no micro-
scopic examination was reported. Again, no clinical history
is given, and the pathological diagnosis, though modern and
very good, is not sufficiently supported by clinical observa-
tions. The collection of cases from modern times has been
simplified by the introduction of the microscope into pathol-
ogy and the nomenclature of tumors based on microscopic

lyirch. Arch., Vol. 145, 1896, p. 191.

2 Edward Boecker, Zur Kenntnis der primaren Lungenkarzinome, Dies.
Gottingen, Berlin, 1910.

14 PRIMARY MALIGNANT GROWTHS OF THE LUNG

study, which latter, though not fulfilling all demands, is most
helpful. But even within the last two years, reports have been
pubhshed where there is no autopsy at all, or one that is very
insufficient, and the microscopic examination is either absent
or summarized in such general terms as "simple carcinoma,"
etc. Nevertheless, though it has taken several years in the
compiling, 374 cases of carcinoma have been collected. It was
thought best to make full abstracts wherever possible, so that
the principal data of each case, both clinical and pathological,
may be at the disposal of the reader, enabling him to use his
own judgment and form his own deductions. The same has
been done for sarcoma, though the latter is infinitely more
difi&cult to get at than carcinoma, — not only because sarcoma
is so much rarer, as will be seen, but because very many cases
are published without sufficient autopsy, and even if autopsied
the almost intolerable confusion in the nomenclature makes
the diagnosis from the printed case wellnigh impossible.

A third collection has been made which contains cases desig-
nated as doubtful, though many of them may be authentic
and valuable. They have been classed as doubtful for
various reasons, sometimes because the autopsy was lacking,
though the clinical observations pointed almost with certainty
to a tumor diagnosis, or it was impossible to decide whether
the case was one of carcinoma or sarcoma, etc.

A few other cases have been assembled which, properly
speaking, do not belong to the subject in hand, but which may
in their symptoms during life so closely resemble primary
growths of the lung that it was thought wise to place them
here for warning and for comparison.

The reader should well understand that no claim is made
for absolute completeness. Many cases were not taken into
our collection either because they were not obtainable, or
were written in a language that could not be readily trans-
lated, or for other reasons. Besides this, too, it was imprac-
ticable to continue collecting material indefinitely, and since
the collection of material has been discontinued numerous
cases have been published, which could not appear in the
present collection. It may be stated also that, with the

INTRODUCTORY (Continued) 15

exception of but comparatively few, the references were read
and excerpted personally. This rather bulky collection is
printed in the form of tables, the first and largest being of
carcinoma cases; the second, sarcoma; the third, doubtful;
and the fourth, a few miscellaneous cases.

CHAPTER III

A FEW HISTORICAL NOTES

Precancerous Influences

OUR knowledge of lung tinnors dates from comparatively
recent times, and the history of its development can be
sketched in a very few words. It may aptly be divided into
several periods. In the first and longest period, lung tumors
were absolutely unknown. This period includes all of
ancient and mediaeval medicine until Morgagni ^ (1682-1772)
laid the foundations of pathological anatomy. It is most
interesting and significant that Morgagni himself was prob-
ably the first to publish the results of several autopsies on
lungs that might be diagnosticated as cancerous, and were
so interpreted by him. It is probable that the first of the
cases which he published as cancer of the lungs was really a
case of primary lung tumor. In this case he describes the
disease of a man sixty years old, which was accompanied by
cough and copious expectoration of a yellowish, rather crude
material, rarely, but then distinctly, stained by streaks of
blood. At autopsy the lung was foimd extremely hard,
adhesions to pleura and mediastina, and nothing else but
an "ulcus cancrosiun" in the right lung.^ The oft-quoted
observations of Lieutaud ^ deal probably with tuberculosis
or diseased pleura, and not with tumor. The cases mentioned
by Van Swieten * must also be considered extremely doubtful.

1 De Sedibus et Causis Morborum per Anatomen indigatis.

2 Loc. cit.

' Historia anatomico-medica, etc., Paris, 1767, Lib. II.
* Comment, ad Boerhaavi Aphorism, Vol. II, 1747.
16

A FEW HISTORICAL NOTES 17

There are a number of French authors about this time ^ who
pubhshed cases as cancerous that cannot be distinguished
with certainty from tuberculosis. G. L. Bayle^ pubhshed
thi'ee cases which he had carefully studied clinically and
equally carefully after death, and he is the author of the
phrase "phthisie cancereuse" which caused so much discus-
sion. The first case he reports may possibly be a primary-
tumor, although this is doubtful. The second case is cer-
tainly secondary after amputation of the arm. The third case
was that of a man seventy-two years old, in which there were
found at autopsy, at the root of the lung, shining white
encephaloid cancerous masses, which were associated with
masses of tuberculosis. It is unnecessary to go into all the
clinical and pathological details and theories on which Bayle
bases his conclusions. There is some merit in his insistence
that cancer and tuberculosis may exist together, although the
tubercles, according to him, are the effect of an acid, and
cancer the effect of an alkali. No clear idea, however, can be
obtained of what he means by cancer and what by tubercu-
losis, and it consequently happened altogether too frequently
that his followers accepted true tubercular cavities as can-
cerous, and vice versa, so that finally great confusion arose
as between tubercular phthisis and cancerous phthisis. His
contention that cancer of the lungs may exist for a very long
time without any symptoms has been corroborated by modem
medicine. On the other hand, he makes no distinction
between primary and secondary tumor.

Besides the French, a number of German authors have
worked on fines similar to those of Bayle, and though the
name "phthisie cancereuse" could not maintain itself for a
very long period, the name "fungus hsematodes," or simply
"fungus of the lung," — especially among German writers, —
was used for all pulmonary neoplasms that bore a suspicion
of mafignancy. Those seeking further information of these

1 Le Dran, Mem. de I'Acad. royale de Chir., Vol. Ill, p. 28, Obs. 22. Also
J. F. Senaux, fils.

2 Journal de Medicine, Tome 73, 1787. Also Recherches sur la Phthisie
pulmonaire, Paris, 1810, p. 299. Also Diet, de Science m6d., Paris, 1810.

18 PRIMARY MALIGNANT GROWTHS OF THE LUNG

historical questions are referred to the EngUsh classics, espe-
cially Stokes/ Graves,^ and Walshe;^ and also to the, for
that period, very complete and thorough works of Reinhold
Kohler,^ and among modern authors, J. Wolff. ^

With Bayle and his followers ends the second period, and
we enter upon the third, characterized by the study of lung
tumors by purely clinical methods, reenforced by gross
pathological anatomy. This period is introduced by Laennec,
the author of TAuscultation Mediate, who, with his great
authority and keen mind, took up the combat against Bayle
and his after all not very progressive theories of the "phthisie
cancereuse" and successfully differentiated the carcinoma of
the lungs, whether primary or secondary, from any form
of phthisical process, even though cavities should be found
coimected with the tumor. He described tumor of the lung
in the clearest terms, under the designation ''encephaloid."
The use of this term, appUed promiscuously to all sorts of
tumors, caused considerable confusion imtil Virchow worked
out a rational classification.

Since the time of Laennec, his lifework, the practice and
perfection of the methods of auscultation and percussion, has
been assiduously continued and by these means a compara-
tively large number of lung tumors has been diagnosticated
and reported. For a long time the necessary distinction
between primary and secondary tumors was not upheld, and
a number of cases were insufficiently observed and carelessly
reported, but still progress in the diagnosis of primary tumor
of the lungs was certainly made. J. Bell ^ is said to have been
the first to diagnosticate with certainty a primary tumor,
which was undoubtedly sarcoma of the lung. The real
founder of this school is Stokes, who, together with Graves,
Walshe, Hughes, and others, laid the foundations of our
present clinical and pathological knowledge of primary lung

' Loc. cit.

2 Clinical Lectures on the Practice of Medicine, London, New Sydenham
Soc, 2d Ed., Dublin, 1848, by J. Moore Neligan.

^ A Practical Treatise on Diseases of the Lung, etc., 4th Ed., London, 1871.

* tJber den Lungenkrebs, Diss. Tubingen, 1847, and Die Krebs- und Schein-
krebskrankheit des Menschen, Stuttgart, 1853.

6 Loc. cit. 6 Table II, No. 3.

A FEW HISTORICAL NOTES 19

tumors. Following upon this period of purely clinical and
gross pathological observation, there comes the time when,
after the fundamental discovery of Schwann, histology be-
comes the main factor in pathological research. After the
great work of Rokitansky,^ in gathering together a very large
material which led to a general cleaning-up and reclassifying
of pathological anatomy, it is above all the name and work
of Virchow that dominate this entire epoch. He was the first
to demand that medicine be lifted out of a maze of hypotheses
and more or less plausible theories to become one of the
natural sciences, based on critical observation and experiment.
The "cellular pathology," with its battle-cry of "Omnis
cellula e cellula," exercised great influence on the study
of tumors. The entire onkology was taken up again and
rearranged in the light of the fact that every cell origi-
nated, not from blastema, not from plastic lymph, not
from diatheses or other exogenic processes, but from cells
alone. 2 The present time is still a part of this period,
and the study of lung tumors must be continued along these
lines.

Notwithstanding the great amount of work that, as has
just been shown, has been done and is still going on, Williams^
is probably correct when he makes the somewhat brusque
statement that "it is necessary at the outset to refer thus
pointedly to the crudeness and immaturity of medical knowl-
edge, because nowhere do these qualities find more striking
exemplification than in the terrible welter of disjointed facts
and contradictory hypotheses that constitute such a large
part of modern Humor science.'" There cannot be any
intention to discuss here the multitude of questions and prob-
lems concerning the etiology and the true natm^e of malignant
growths in general. The many questions of fundamental
import, the attempts into the field of etiology, the innumerable

^ Lehrbuch der pathol. Anatomie, 1844.

2 Thiersch, Der Epithelialkrebs namentlich der Haut, Leipzig, 1865; Wal-
deyer, Uber den Krebs, Volkmanns Samml., 1873, No. 33; Bard, La Specificity
cellulaire et I'Histologie chez I'embryo, Arch, de Phys. normal, et path., 3 Ser.,
7, p. 406, the author of the aphorism: "Omnis cellula e cellula ejuedem
generis." ' Loc. cit.

20 PRIMARY MALIGNANT GROWTHS OF THE LUNG

theories, and above all, the enormous experimental work that
has been done within recent years, — all this is obviously
beyond the scope of this little monograph, which is to be
devoted solely to the study of lung tumors.

Nearly all the types of malignant neoplasms that occur in
other parts of the body are also to be found among the
primary growths of the lung, but before taking up the direct
study of these tumors, some attention should be given to
the conditions which have long been called "predisposing
causes," but which latterly and more significantly are termed
'^ precancerous conditions and affections."^

First, the influence of race on carcinoma. According to the
latest statistics, race and geographical distribution seem to
have a decided influence on the incidence of malignant
growths.2 In the very thorough work of Dr. Levin,^ sufficient
proof appears to be found that there is less cancer among the
American Indians and American negroes than among
the whites. Tuberculosis decimates the American Indians,
while they are almost immune to cancer. This seems to
contradict the statistical conclusions arrived at by Behla.^
Levin notes, too, that it is usually sarcoma or epithelioma
of the different external parts of the body, which are neces-
sarily more exposed to mechanical irritations, that affect the
primitive races. In civilized nations there is a prevalence
of carcinoma of the internal, parenchymatous organs. The
following sentence, quoted from Levin, is important: "Thus
the conclusion is forced on one's mind that, while every
human being may carry within himself the X which may
develop into cancer, it is the modern civilization and the
conditions created by it that give rise to the mediate causes
which produce the disease." The facts, indeed, at present
available, support the conclusion that the white races,

1 All these data and figures have evidently been worked out principally for
carcinoma, sarcoma being brought in now and then incidentally only, probably
because of its rarity, possibly because no difference was made between the
two.

2 Carl Lewin, Die Bosartigen Geschwiilste, Leipzig, 1909. Also Williams,
loc. cit.

' I. Levin, Cancer among the American Indians, Zeitschr. f. Krebsforsch.,
Vol. X, Heft II, 1911. ^ Loc. cit.

A FEW HISTORICAL NOTES 21

especially in Europe and the United States, can claim the
greatest mortality from malignant growths, and there is
only China, perhaps, that can compete with them in this
respect. It is reasonable to suppose that this applies also
to lung tumors, though there are no special statistics.

Next, the question of heredity. This has always been
considered a very potent factor in the etiology of malignant
neoplasms in general. Josefson and Pfannenstill ^ have
already noticed, however, that this does not apply to lung
tumors. They have found only one case of accredited hered-
ity among their seventy cases. According to Table I, in 290
cases of carcinoma heredity is not mentioned. As many of
these cases are very superficially reported, and as in many
others no clinical history is given, but the cases are simply
introduced as pathological specimens, it is likely that among
these 290 cases there may be many where the factor of hered-
ity was simply overlooked. In twelve cases only it was posi-
tively stated that there was a hereditary strain of cancer in
the family, and in sixty-eight instances it was asserted that
no hereditary strain could be discovered. According to the
German Sammelforschung, in 9% of the males and 10.3% of
the females hereditary predisposition for cancer was found.^
The experimental study of tumors has thus far not furnished
any decided proof of the value of heredity as a causal factor,
and Bashford is inclined to deny its influence altogether. It
follows, — though the figures are very uncertain, — that the
incidence of malignant growths of the lungs does not appear
to be seriously affected by hereditary strain.

The influence of sex. M. Askanazy* maintains that there
is a distinct connection between premature sexual develop-
ment and the development of malignant growths. Among
tumors of other kinds he quotes also Linser,* who reported
the case of a boy thirteen years of age with a complete

1 Primary Cancer of Lungs, Nov. Med. Arch., Stockholm, 1897, N. F. VIII,
Festband, Axel Key; and Lubarsch and Ostertag, Ergebnisse, Wiesbaden, 1904,
Vol. VIII, 1902.

2 Quoted from Lewin, loc. cit.

3 t)ber Sexuelle Friihreife, Zeitschr. f. Krebsforsch., Vol. X, Heft. Ill, 1910.

4 Virch. Archiv., 1899, Vol. 157, S. 281.

22 PRIMARY MALIGNANT GROWTHS OF THE LUNG

development of hair such as is seen after development of
puberty. He died of a tumor in the left pleural cavity
and mediastinmn which, on examination, showed absence of
elastic fibres, in stroma, no cihated epitheha, the epithehal
cells in certain places still stratified. The natural history of
these evidently congenital tumors is as yet entirely obscure.

It has always been maintained that males are by far more
frequently subject to lung tumors than females. Tables I
and II corroborate this. Among the 374 cases of carcinoma
of the limgs, there are 269 males, or 71.9%; ninety-three
females, or 24.8%; twelve in which the sex is not stated.
In the same way, among ninety-four sarcoma cases, sixty-
three, or 67%, are males; twenty-eight, or 29.7%, females;
three where sex is not stated.' The domestic life led by
women, with their consequent retirement and immunity
from the irritations and traumatisms which must be frequent
in the more unprotected life of men (the abuse of tobacco and
alcohol, the many trades and vocations which are accom-
panied by irritations of the respiratory organs, etc.) has been
adduced in explanation of this fact. The entire subject is
not yet ready for final judgment.

The age of the patient. It is indisputable that age has a
certain influence upon the incidence of both carcinoma and
sarcoma. Statistics seem to show that carcinoma, roughly
speaking, is a disease of that period of life which follows
puberty after its completion, while, on the other hand, sar-
coma as a rule is a disease of the earher years of hfe. But
there are exceptions, and no age is entirely exempt from
either type of tumor. The following figures, gathered
from Tables I and II, clearly illustrate this. It is evident
from this that the majority of carcinoma cases hes beyond
the age of forty and attains its maximum between the ages
of fifty and sixty. Descending slowly there are still two cases
remaining between eighty and ninety, while the majority of
sarcoma cases lies below the age of forty, cUmbing up slowly
from the decade between ten and twenty, reaching the
maximum between thirty and forty, declining again, slowly,
and there are still five cases between seventy and eighty.

A FEW HISTORICAL NOTES 23

The first decade, from birth to ten years, seems to be kommie
from carcinoma (without counting, of course, the few cases
of congenital tumor).

Carcinoma

Sarcoma

Age not stated

1-10

10-20

20-30

30-40

40-50

50-60

113

50-60

60-70

70-80

80-90

2
374

These figures tally satisfactorily with the age tables given
by many authors, for instance Fuchs.^

The question of the influence of age upon the incidence of
maUgnant neoplasms is one that is intimately connected
with certain problems that have of late years been thor-
oughly studied and widely discussed, — the problems of growth
and of senility in their physiological and pathological bearings.
The older theories, such as those of Thiersch ^ and others,
that as the body grows older the interstitial tissue undergoes
a change, the equilibrium between this and the epitheUum
is impaired, in consequence of which the epithelial tissue
proUferates and tends to form carcinoma, while, on the
other hand, in youth the connective tissue group is apt to
overstep the bounds set to it and thus sarcoma and similar
tumors may be formed — these theories no longer hold
good. It has just been shown that no age is absolutely
immune from the formation of neoplasms and that even in
intra-uterine life tumors of all kinds may be developed.
These facts seem to lead to the unavoidable conclusion that
deeper and more complex principles are involved. It is
altogether foreign to the purpose of this study, and would
require a book by itseK, to go into details concerning the
modem theories of growth and senility. It will suffice to say

^ Beitrage zur Kasuistik des prim. Lungencarzinoms, Diss. Leipzig, 1890.
* Log. cit.

24 PRIMARY MALIGNANT GROWTHS OF THE LUNG

that developmental energy of a high degree becomes active
as soon as the sperma enters the ovum. After that, until
the organism is fully grown, there is a continuous balancing
of energies as manifested in highly compHcated chemical
and physical processes. Immediately with the completion
of growth, the changes begin which lead to senescence and
final destruction of the body. The study of the intricate
chemistry and physics of growth, regeneration, and senes-
cence is by no means concluded, but has in reaUty only just
begun. The relation of these problems to the formation
and development of neoplasms is as yet sufficiently obscure,
but many a single ray of light shed here and there justifies the
hope of further enlightenment in the near future.

It is of special interest in this connection to study the work
of Rossle,'^ from which only a few conclusions may be quoted.
It appears to him as certain that hypersemia is able to
produce a considerable increase in the number of those cells
which are organically an integral part of the matrix, and
for that reason are subject to the laws of nutrition specific
to the latter. Hypersemia, however, cannot produce those
biological alterations in the cells in consequence of which
endless proliferation is caused. Rossle agrees, also, that
hypersemia alone cannot account for the development of
tumor, but must be associated with many other factors,
among others, probably senescence. His aphorisms con-
cerning senility are also most plausible and interesting. There
may be senescence of the entire organism or of individual
organs only. SeniHty does not attack different parts of the
body simultaneously. While one part may long ago have
become senescent, other organs may as yet be quite youthful.
According to Rossle, the general law may probably be that
the more intense the function, the sooner the cell grows old.
It is doubtful if, with all their plausibihty, these theories will
stand before more than a superficial investigation. Rossle
further asserts that epithelium in general retains its juvenile
status approximately during the entire life of the individual

1 Die RoUe der Hyperamie und des Alters in der Geschwulstentstehung,
Munch. Med. Woch., 1904, p. 1330.

A FEW HISTORICAL NOTES 25

and can be rejuvenated by karyokinesis and regeneration.
The earlier in the course of the life of an organism a tissue
becomes senile the earher it will be possible for tumors to
be developed from this tissue, for according to Rossle it
is not those cells and tissues which have become senile,
but those which have remained youthful and capable of
reproduction and regeneration, which form the origins of
these tumors.

CHAPTER IV

PRECANCEROUS INFLUENCES {Continued)

AS all these questions are most intimately connected with
the question of the etiology of tumors, it will be best
to say a few words in this place on the subject of etiology, at
present the centre of so much discussion and labor. The
despairing exclamation of Heyf elder, ^ — "Je passe sous
silence Fetiologie et le traitement de cette maladie qui,
jusqu'a present, est hors du domaine de Tart," — is for-
tunately no longer true in its entirety. But still it must be
confessed that, with all the colossal labor expended on the
question of the etiology of tumors in the last half-century, the
fundamental cause, the unknown X, that lies at the very
bottom of all these manifold processes, is still entirely obscure
and there is as yet not even a sufficient basis for an intelhgent
statement of the question that would seem to promise any
result. What we know to-day of the physiology, the chemis-
try, and physics of growth and senihty seems to suggest that
mahgnant neoplasms might in general be accounted for in
either one of two ways, and the discussions as to etiology
actually do gravitate about these two points. Firstly, one
might suppose, seeing that the greatest energy and the
foundations for its proper balance are put out in early foetal
life, that neoplasms are based ultimately on some earUer or
later intra-uterine disturbance. This is, indeed, the theory
that was furnished and elaborated by Cohnheim and his
followers. 2 Cohnheim, however, did not look upon all this

^ Du Cancer du Poumon, Arch. Gen. de Med., Vol. 14, 2d Series, 1837,
p. 345.

^ Many years before Cohnheim, in the paper by Langstaff (Table II, No.
49) in 1818, that author says ^p. 345) that he has noticed "pulpy tumors in the
lungs of adult persons who had not been affected during their lives with the
least symptoms of pulmonic disorder and who died of active disease of a

PRECANCEROUS INFLUENCES (Continued) 27

from the mere standpoint of general physiology and of chem-
istry, but assmned remnants of embryonal tissue in this
or that organ which, left over, as it were, and endowed
with proliferative energy, might under favorable conditions
become active and produce tumors.

This theory of Cohnheim, which, for reasons not necessary
to state here, seemed untenable, was again revived, though
in a much modified form, by Borst ^ and his followers. Borst
assumed, as the necessary foundation for the formation of neo-
plasms, early disturbances in the intra-uterine development,
the nature of which is not as yet accurately known. Accord-
ing to him, it is not necessary to assume the bodily presence
of actual embryonal remnants. He remarks that, according
to his view, it is highly probable that each organ has its own
peculiar onkology. A true carcinoma is not developed out of
any, no matter how irregular, form of inflammation, no trans-
formation into carcinoma is effected when short, glandular,
cuboid cells happen to be turned into high cylindrical cells
of entirely different structure or when high cylindrical
cells happen to be changed into others, again of different
structure and of different function, or when single layers of
pavement epithelium become stratified into numerous layers
of epidermal cells. All these and many more deformations of
epithelium might be mentioned which, according to Borst's
view, would in no wise transform the particular growth
in hand into a carcinoma. What Borst does require, and
requires without exception, is just that transformation of an
epithelial cell into one of cancerous character, on the details
of which so many express differing opinions, and the character
of which is so difficult to describe and yet is so readily accepted
as a matter of belief.

different description in other viscera." He is inclined to think that fungus
haematodes and cancer and scrofula "have their origin perhaps with the
formation and development of the natural parts of the foetus in utero and
that they remain, after the birth of the individual, in some instances dormant
or inactive for a series of years, and in all only require a peciiliar morbid
excitement to occasion this increase and destructiveness."

^ Die Lehre von den Geschwlilsten, Wiesbaden, 1902. Uber atypische
Epithelwucherung und Krebs, Verhand. Deutsch. Path. Ges., Vol. 6-7, 1903-
1904, p. 110.

28 PRIAIARY MALIGNANT GROWTHS OF THE LUNG

It would be most interesting to continue in detail the
history of the various theories and speculations which have
led to the present state of our knowledge of mahgnant
tumors. This is impossible, because the subject of this
essay is tumors of the lung, and not mahgnant growths in
general. The necessity of closely adhering to this special
subject is still more imperative because of the enormous
material on tumors in general pubhshed from year to year,
a few examples of which have abeady been mentioned, as
Willams,^ Borst,^ the various writings of Ribbert and espe-
cially his latest.^ But even a simple catalogue of the more
important writings on these subjects, with only carcinoma
as a subject, would be enough to fill a small book. Does it
not after all seem as if one theory were as good as another
and might, by some clever reasoning, be selected according
to the subjective taste of the author who elects to defend it?
In the writer's opinion, the best evidence appears to be on the
side of Borst and his followers. Be that as it may, one can
only reiterate again and again that, with all the labor and time
spent on these questions by workers in many separate fields
of research, and especially the tremendous amount of experi-
mental work that has of late years been done by Ehrlich
and his school, by Bashf ord and many others, — while it has
added much that is valuable to our general knowledge and
has been of immense service to our better understanding of
many medical and biological problems, especially of onkology,
— in spite of all this, no light has been shed upon the ultimate
etiology of tumors, and the words of Kraske ^ are in the main
still true, — ''We know no more to-day of cancer than did our
grandfathers."

That cases of tuberculosis the world over, thanks to the
preventive work done everywhere, are steadily diminishing
in number seems indubitable. There is, as we have seen, a
great deal of legitimate doubt as to the increase of carcino-
sis. Behla ^ has pointed out that by adequate disinfection of

^ Loc. cit. ^ Loc. cit.

^ Das Karzinom des Menschen, etc., Hugo Ribbert, Bonn, 1911.

« Naturforschen^ersammlung in Freiburg, Marz, 1902.

^ Loc. cit., p. 177.

PRECANCEROUS INFLUENCES (Continued) 29

tubercular sputum, ulcers, and numerous other places where
tubercle baciUi may be found or suspected, by proper
isolation and proper sanitaria, etc., the progress of tuber-
culosis can to some extent be arrested and that a much
greater advance in the arresting of this scourge of mankind
may be hoped for in the future. It is quite different with
carcinoma. There is as yet no known primary cause for
malignant growths. Among the multitude of contagions
that we know at the present day, none has been found that
seems to have any connection, causative or otherwise, with
carcinoma or sarcoma. Carcinomatosis, therefore, does not
show any similarity with the contagious character of tuber-
culosis. It does not seem to spread infection from individual
to individual. It is more than doubtful whether environment,
as some authors maintain, plays any active part in the
development of mahgnant growths. Behla has not suc-
ceeded in proving that special forms of vocation, trade,
occupation, etc., or calling of any kind, have any active
part in the causation of lung tumors. It is true enough
that certain kinds of work are apt to produce inflammatory
conditions (bronchitis acute or chronic, anthracosis, siderosis,
chronic indurative pneumonia, and others), and the locaU-
zation of tuberculosis may possibly be determined by such
factors. But it has never been proven that any increased
tendency toward the development of mahgnant tumors is
caused thereby.^

It may be convenient in this connection to refer briefly to
the so-called cancer of the lungs as occurring in the mines of
Schneeberg, Silesia, Germany.^ It was thought that here at
least was proof positive of the production of mahgnant growths
solely by the injurious effects of purely exogenic influences
as furnished by irritating occupations. In this small Silesian

^ Conf. the work of Williams, loc. cit.; Karl Kolb, Der Einfluss des Berufes
auf die Haufigkeit des Krebses, Zeitschr. f. Krebsforsch., Vol. IX, Heft III,
Berlin, 1910; Behla, loc. cit., and many others.

2 Hesse, Das Vorkommen von primarem Lungenkrebs, die Bergkrankheit
in den Schneeberger Gruben. Vierteljahrschrift f. gerichtliche Medizin, 1879,
pp. 296 ff. Also Ancke, Lungenkrebs der Schneeberger Erzarbeiter, Diss.
Miinchen, 1884. Also Komer, Munch. Med. Woch,, 1888, No. 11.

30 PRIMARY MALIGNANT GROWTHS OF THE LUNG

town there were eight mines extending to a depth of fifteen
hundred yards, from which cobalt, nickel, and bismuth
were obtained. There were from six to seven hundred men
employed in the mines, and of these the yearly mortaUty,
excluding accidents and the like, was about twenty-eight to
thirty-two, of which twenty-one to twenty-four were from
carcinoma of the lungs, so that a total of seventy-five per
cent of all miners in this town died from this disease. The
worker was never affected until after twenty years of mine
work, usually later, while the worker who siurvived fifty
years of mine work was generally immune. Heredity can be
excluded, for only those who worked in the mines, and worked
steadily, were afflicted. Those who did not work continu-
ously in the mines, or who had other occupations besides
mining, or who lived better on the whole, might live to be
seventy years or over. The symptoms need not be described
here. The autopsies showed that the disease always com-
menced from the root of the lung where the lymph nodes
were involved and enlarged, ranging from the size of a walnut
to that of a fist. Sometimes secondary tumors in the subcutis
of the thorax, visible from without, occurred. The timiors
were examined frequently, especially by E. Wagner,^ who
found the nodules to be true Ijmapho-sarcoma. Cohnheim ^
had already hinted at the likelihood of these tumors not being
real tumors at all, but products of some infection. The ques-
tion was studied in all directions. It was found that only
those who did actual mining, and for a considerable number of
years, were attacked by the malady; that there was no local
irritation caused by the nickel or cobalt or bismuth particles,
but that it was a form of poisoning due to the arsenic found
in some quantity in those ores. In other mines of cobalt,
nickel, etc., in Sweden, Hungary, and the Tyrol, where the
ore contained no arsenic, the disease did not occur. Since
the authorities have sufficiently ventilated the mines and
have properly regulated the lives of the miners, nothing has
been heard of the ^'Schneeberger Lungenkrebs."

^ Eulenberg's Vierteljahrschr. f. Gerichtl. Medizin.
2 Vorlesungen, Vol. I» p. 718.

PRECANCEROUS INFLUENCES (Continued) 31

Trauma. Much stress has been laid on traumatism as an
important factor in the development of malignant neoplasms.
By "traumatism" is meant here the injuries of the grosser
kind, like severe contusions by blows, falls, and similar
occurrences. It is always claimed that these severer forms
of traumatism have some intimate and direct relations with
the development and growth of maUgnant tumors; in fact
are the growth-determining element. Statistics, however,
do not seem to bear this out. Among the material col-
lected in Table I dealing with carcinoma, there are but six
cases in which traumatism in the ordinary larger sense is
recorded.^

The really effective action of traumatism has for a long
time been considered, as displayed in the development of
sarcoma. Among the ninety cases tabulated on Table II,
there are only two cases (Nos. 15 and 51) in which trauma is
recorded. This seems to eliminate once and for all the idea
that traimiatism of the grosser kind, at least, has any part in
the development either of sarcoma or of carcinoma. Granted
that the figures are very uncertain and clinical history and
careful observations lacking, the small percentage of cases in
which trauma is associated with the formation of tumors can
only be due to a coincidence. It might, of course, be claimed
that the tumor, — carcinoma or sarcoma, — had been latent
before trauma, and that the trauma merely hastened the
growth of the tumor. This is capable neither of proof nor of
disproof and must remain for the present a matter of beUef
and not of knowledge. Experimentally, so far as can be seen,
convincing testimony has not been brought forward in either
direction, but, as we must constantly keep in mind, no
experimentation of any kind has as yet been able to produce
an experimental case of malignant growth. The question
of traumatism is, of coiu-se, still much discussed and it is
surprising to note the lengths to which some authors are
prepared to go. Herzfeld,^ for instance, concludes his work
with the sentence, ^'Ohne Trauma, kein Tumor" (No tumor

1 Nos. 81, 104, 115, 158, 161, and 177.

' Tumor and Trauma, Zeitschr. f . Krebsforsch., Vol. 3, 1905, p. 73.

32 PRIMARY MALIGNANT GROWTHS OF THE LUNG

without trauma). One interesting case is reported by
Schoppler/ in which a fall down stairs with severe contusion
of the left mamma was supposed to have given rise to a
carcinoma, that portion of the breast having been, supposedly,
healthy before trauma. It was quickly operated and the
diagnosis corroborated by the microscope. The author
considers this a convincing proof of the development of a
carcinoma from a single traumatism. The writer does not
think that he has proved his case, since, in order to have
absolute proof, it would be necessary to have demonstrated,
microscopically and otherwise, before the fall, that the
portion of the breast affected had been entirely healthy.
One must coincide with Bostrom^ in so far as he, with
other authors, claims that no malignant tumor can be de-
veloped after a single traumatism, from tissue previously
healthy. It is not possible, however, to accept uncondi-
tionally his further statements, that these large traumatisms
may act as coincidental irritants and causes of mahgnant
growths.

Besides these blows and contusions, falls and all the grosser
forms of traimiatisms, those smaller irritations which lead to
chronic infianmiations and indurations, to hyperplasia, and
often to hj^ersecretion and hyposecretion of the tissues, must
be considered under the general head of traumatism. On
this subject there is also a very large literature which cannot
be mentioned here. A part of it will be found in Schoppler.'
Besides the usual standard works, there are also the publica-
tions of Brosch,^ Schuchhardt,^ and Ropke.^

Chronic irritations affecting the respiratory organs are
numerous and are supposed by many to play a very active

iZeitschr. f. Krebsforsch., Vol. 10, No. 2, 1911, p. 219. Einmaliges
Trauma und Carcinom.

2 Traumaticismus und Parasitismus als Ursachen der Geschwiilste, Giessen,
1902. » Loc. cit.

* Theoretische und experimentelle Untersuchungen zur Pathogenese u.
Histogenese der malignen Geschwiilste. Quoted after Wolff, loc. cit.

* Beitrage z, Entstehung des Carcinoms aus chronischentzundlichen Zu-
standen der Hautdecken und Schleimhaute, Volkmanns Samml. klin. Vortr.,
No. 257, 1885.

6 Arch, f . Klin. Chirurgie, Bd. 78, 1905, H. II.

PRECANCEROUS INFLUENCES (Continued) 33

part in the causation of tumors of the lung. Such causes
are supposed to account for the predominance of males over
females in the occurrence of tumors.^ It is very generally
stated that the right side is the favorite localization of car-
cinoma of the lung, and this is supposed to be in consequence
of the anatomical and physiological conditions. The right
bronchus is shorter and wider than the left, its course is
considerably straighter, and it seems natural enough that
irritating substances, both chemical and mechanical, are
aspirated more easily into the right than into the left
bronchus. The following figures calculated from Tables I
and II seem to show that for carcinoma there is a pre-
dominance in favor of the right side amounting to thirty-
one cases. For sarcoma, on the other hand, there seems
to be a predominance in favor of the left side. The figures
calculated from Table III show no predominance of either
side.

Carcinoma Sarcoma

Right side 188 Right side 36

left 157 left 51

both 18 both 2

doubtful 3 not stated 5

not stated 8 94

374

Comparison of these figures shows results so inconstant and
differences so slight that it would not be wise to build any
theories thereon. A. FrankeP comes to a similar conclusion,
though based on a much smaller material.

Tuberculosis. The authority of Rokitansky for a long
time sustained the dogma that carcinoma and tuberculosis are
incompatible diseases; in other words, that where tubercu-
losis is found a cancer cannot develop. Another view, at
one time popular, is expressed by an aphorism of Crazet^ —
"The cancerous easily become tuberculous, but the tuber-
culous do not easily become subject to cancer." Actual

1 Conf. p. 22, Chap. III. " Loc. cit.

3 Coincidence et rapport du tuberculose avec le cancer, These de Paris,

1878.

34 PRIMARY MALIGNANT GROWTHS OF THE LUNG

experience has since shown, not only that carcinoma, espe-
cially of the cancroid variety, is sometimes found in a tuber-
culous cavity, but that ordinary pulmonary tuberculosis, with
breaking down of tissue and formation of cavities, as well
as miUary tuberculosis and locahzed tuberculosis in other
organs, may be associated with pulmonary neoplasms. In
some cases the diagnosis of associated pulmonary neoplasm
and tuberculosis has been made during life. A selection of
cases taken from the collected material will serve to illustrate
the association of mahgnant growths and tuberculosis.
Tumor was present in every case, whether expressly men-
tioned or not.

Table I

54 Cohn

Autopsy

Tuberculous cicatrix in right apex and in Bau-
hini's valve

87 Friedlander

Autopsy

Cancer in left bronchus and tuberculous cavity
left lung

98 Gougerot

Clinical

Pulmonary tuberculosis of old standing

106 Harbitz

Clinical

Tuberculous family history

257 Perrone

Sputum

No tubercle bacilli

Autopsy

Tubercular cavity at left apex, wall of cavity
penetrated by tumor

295 Sehrt

Autopsy

Carcinoma right bronchus, extensive ulcerative
tuberculosis

343 Wolf

Clinical

Chronic phthisis

Autopsy

Tubercular cavity left lung and tumor

344 WoK

Clinical

Chronic phthisis

Autopsy

Tubercular cavity right lobe and tumor

346 WoK

Clinical

Signs of pulmonary phthisis

Autopsy

Tumor left apex, mihary tubercles over right
pleura

348 Wolf

Autopsy

Tumor of right upper lobe surrounded by fresh
miUary tubercles, both suprarenals tubercu-
lous, tuberculous ulcer in ileum

349 Wolf

Autopsy

Nodules root of right lung, excrescences on
membrane of larger bronchi, bifurcation sur-
rounded by large tumor, fresh miUary tuber-
culosis of both lungs

350 Wolf

Autopsy

Tuberculous lobe, tuberculous pleuritis

356 Wolf

Autopsy

Carcinoma of main bronchus, miliary tubercles
in liver

359 Wolf

Clinical

Anorexia and emaciation followed by signs of
right pulmonary phthisis

365 Wolf

Clinical

Pulmonary phthisis

373 Wolf

Clinical

Symptoms of tuberculosis with bacilli

Autopsy

Lesions of old and more recent phthisis

374 Wolf

Clinical

Diagnosis first as tuberculosis, then as ss^jhilis

PRECANCEROUS INFLUENCES (Continued) 35

Table II

36 Hildebrand Tubercle bacilli in sputum

79 Schnick Tubercle bacilli in sputum

The cases will probably be much more nmnerous m
future, m proportion to the increasing attention given to
this subject at autopsies and microscopic examinations.
Some authors appear to take a somewhat extreme stand
regarding the relation between tuberculosis and tumors
generally, and of tumors of the limg especially. For in-
stance, Aronson ^ cites twenty-two cases of his own practice
in which tuberculous patients had one parent or both suffer-
ing from carcinoma. He even goes so far as to suggest the
possibility that the tubercle bacillus under favorable con-
ditions might produce carcinoma, and refers to the lupus
carcinoma as the connecting link between tuberculosis and
carcinoma. It is sufficient to quote the following sentence:
''The phthisical diathesis is not only inherited from parents
suffering from tubercular phthisis, but also from those suffer-
ing from carcinoma. Etiologically considered, carcinoma,
lupus, tuberculosis, all these belong most probably to a
single family." As a counterpart to these exaggerated
statements, Bayha^ describes the so-called lupus epithelioma
and declares this form of epithelial proliferation in no wise
cancerous or malignant. He shows that genuine carcinoma
develops much oftener on active and fresh lupus than on
lupus scars. The proclivity of carcinoma to develop from
lupus, and especially from lupus scars, has been mentioned so
often as a fact beyond dispute that it is important to note
the results of Bayha's investigation. He says distinctly that
there is no direct transition from lupus to carcinoma, but that
the malignant epithelium prohferates into the interpapillary
depressions. WilUams ^ reiterates his view that as tubercu-
losis declines, carcinoma necessarily increases. It is also his
belief that the systemic depreciation that follows as a conse-

1 Beziehungen zwischen Tuberculose und Krebs, Deut. Med. Woch., 1902,
No. 37, p. 842.

^ Uber Lupus Carcinom, Bruns, Beitrage zur Klin. Chir., Vol. Ill, 1888,
p. 1. » Loo. cit., pp. 337 ff.

36 PRIMARY MALIGNANT GROWTHS OF THE LUNG

quence of fresh tuberculosis, and even of tuberculosis only
recently healed, is an undoubted factor in the etiology of
cancer. On the other hand, he readily agrees to the fact that
while a considerable amount of old, healed, calcified tuber-
culous products may be found associated with neoplasm in
the lungs, this association has no further meaning than that,
cicatrized tuberculosis being so extremely common, the ordi-
nary percentage is also found in the cancerous. Furthermore,
F. P. Weber and many others suggest that old, quiescent
tuberculous foci, not yet completely cicatrized, may be again
started into activity by the local as well as systemic effect
of the cancer, which naturally tends in a great measure to
lower the patient's vitality. This, however, is a speculation
of which we know nothing.

The subject of tuberculosis in its relations to carcinoma
should not be closed without mentioning the theories of
Kurt Wolf."^ Wolf distinguishes closely between bronchial
carcinoma and carcinoma of the lung proper. Of the latter
he reports nine cases, of carcinoma of the bronchus twenty-
two. ^ He points out that bronchial carcinomata are nearly
always found in those places which are most subjected to
slight, but chronic, irritations, especially on the right side
and more particularly near the bifurcations. He does not so
much refer to the tracheal bifurcation, but more to the bifur-
cations of the second, third, fourth, and following orders.
NatiKally, all the irritations of aspiration, of dust, tobacco,
and so on, as well as coughs, are apt to centre about these
points. It is there that Wolf most frequently finds very small
melanotic lymph nodes which, even at a very early stage,
are tuberculous. Sooner or later a minute perforation into
the bronchus takes place, into which the melanotic contents
of the Uttle node are discharged ("Pigmentdurchbruch").
The lymph nodes on the down track toward the hilus of
the lung, and of the hilus itself, become enlarged in the
course of the process. It is Wolf's contention that these
little melanotic lymph nodes are apt to be tuberculous; that

1 Wolf, Der Primare Lungenkrebs, Fort. d. Med., 1893, Vol. 13, Nos. 18
and 19. 2 Conf . Table I.

PRECANCEROUS INFLUENCES (Continued) 37

when penetrating into the bronchus or developing at the
root of the lung they act as a chronic irritant at the locali-
zations most exposed. This "Pigmentdurchbruch,"i Wolf
claims, is sufficient, in persons hereditarily predisposed, to
start the development of malignant growth. This malignant
neoplasm then proliferates in the bronchus first affected,
travels along the ramifications of the bronchial tree, pene-
trates into the lungs, and forms more or less extensive timiors.
This theory of Wolf has been the subject of some discussion,
but has not been generally adopted. The presence of the
tubercle bacillus or any active tuberculous process has never
been definitely demonstrated in these minute lymph nodes
or their further development. He finds, out of the thirty-
one cases which he reports, eleven cases which exhibit, not
cicatrized and inactive, but mostly fresh and active tuber-
culous processes, by the side of indubitable primary malig-
nant neoplasms in the lungs. This, however, does not suffice
to prove his ingenious theory.

That carcinoma does occur on various cicatrizations,
especially of the skin or mucous membrane, is a fact. It is
only necessary to refer to the carcinoma on lupus, previously
mentioned in this connection, on ulcer of the stomach, on
leukoplakia, gall bladder, etc. This form of precancerous
affection evidently is not concerned in limg tumors, unless we
except the theories of Wolf, just briefly outhned, or of some
other authors, who find in tuberculous cicatrizations or
tuberculous ulcers a formative irritant for the development
of carcinoma.

An attempt has been made to obtain some knowledge of the
duration of carcinomatous disease from Table I. Reliable
values are, however, not easily obtainable, and it is possible
to give only an approximate and very defective notion of the
duration of primary carcinoma of the lung. The reasons for
this are obvious. Many authors neglect to give any data
from which the duration might be deduced, and the patients
themselves are often so little self-observant and so careless

> This "Pigmentdurchbruch," so fax as the writer knows, has been demon-
strated only a single time.

38 PRIMARY MALIGNANT GROWTHS OF THE LUNG

of their physical condition that they seek medical aid long
after the first appearance of symptoms, the date of which,
therefore, can no longer be fixed. Finally, the first appear-
ance of symptoms does not necessarily coincide with the
beginning of the disease. Among the 374 cases tabulated in
Table I, there are no means of calculating the duration in
230 cases. The longest duration given is five years, the
shortest two weeks. ^

^ For details, see Appendix A.

CHAPTER V

PATHOLOGY

THERE is an old aphorism saying that those organs
most disposed to secondary tmnors are least disposed
to the formation of primary neoplasms. The limgs are
undoubtedly a favorite locaUzation for secondary tumors,
but primary neoplasms are by no means rare. All the types
of tumors represented in the onkology of other organs may
also be found in the limgs.

The gross appearance is not uniform or characteristic. It
differs according to the peculiarities in each individual case.
For carcinoma of the lungs, the older writers distinguish
only between encephaloid, or what they called medullary,
cancer (" Markschwamm " and fungus hsematodes) and the
infiltrated form, the names being given merely to indicate
external differences. Jaccoud ^ mentions that primary cancer
of the lung is nearly always of the encephaloid variety and is
seen either "en masse" or in a more infiltrated form. He
considers the "cancer en masse" as the more frequent. It is
not easy to determine just what kind of tumor, — sarcoma
or carcinoma, — Jaccoud had before him. A much greater
variety in gross appearance of this class of tumors is now
recognized.

One form that occurs occasionally is that of a single
nodule, usually quite small, surrounded perhaps by a few
minute miliary nodules deeply buried in the lung tissue of one
lobe, producing only very slight or possibly no symptoms
during life, and as a rule discovered by mere accident at
autopsy. These cases are rare. The writer has seen two.

There is the so-called mihary form of carcinosis, which in

^ Jaccoud, Legons de Clinique m^dicale, 1871-72, p. 454, Cancer de pou-
mon; Traits de pathologic interne, Vol. 2, p. 120.

40 PRIMARY MALIGNANT GROWTHS OF THE LUNG

the gross resembles very nearly an eruption of miliary tuber-
cles.^ There is perhaps this difference, that the little nodules
are somewhat larger than the tubercles and have not the
peculiar grayish translucent appearance, but are more whitish
and generally distributed along the lymphatics.^ The reader
is referred, for a history and description of the acute miliary
carcinosis in general, to J. Wolff. ^ As for the lungs, there
seems to be no doubt that a miUary carcinosis actually exists,
as Rokitansky* and Elisberg^ hold, but it is probable that
these cases are not always primary. It is very much more
likely that they are secondary to some small tumor that —
possibly owing to lack of symptoms, possibly because hidden
away in the depths of some bulky organ — was not detected.
The nodular form of primary carcinoma of the lung as a rule
involves in its beginnings only a portion of one lung, while
metastatic carcinomatous nodules in the lungs are apt to be
distributed throughout both lungs. The nodules are found
of varying sizes, from that of a cherry pit or walnut to that
of an egg, small apple, or even a human fist. They are not
usually confluent, but are separated from each other by
lung tissue. The boundary between the tumor and the lung
is sharply defined. As the process continues, the lung tissue
intervening between nodules often becomes involved in
secondary inflammatory and degenerative conditions, and the
nodules, as they increase in size, may merge one into the
other. Jaccoud,® and since his time others, have been of
opinion that cavities and breaking down of tissue within
these nodular carcinomata do not occur, or at all events
are very rare. On the contrary, however, the material col-
lected in Table I will show that the formation of irregular
cavities, especially in the larger nodulated tumors, is a
common occurrence. The gross appearance on section of
these nodules varies according to the kind of tumor and the
condition in which it happens to be, and it is therefore not

^This form was first described by Demme, Schweiz. Monatschrift f.
prakt. Medizin, Jahrg. Ill, 1858, No. VI.

2 Conf. Wunderlichs Archiv., 1857. ' Table I, No. 80.

» Loc. cit.. Vol. II, pp. 398 S. " Loc. cit.

« Loc. cit., 1856, Vol. I, p. 255.

PATHOLOGY 41

possible to present a uniform and generally applicable
description. One may be sure, however, that besides the
usual grayish-white or yellowish or pinkish-white tumor
material there may be found pathologically altered bronchi
and vessels, bronchiectatic dilatations, and, as has been
said, occasional cavities. The cavities have ragged, irregular
walls, consisting of tumor. Stumps of vessels and bronchi
often protrude into them from the walls. The cavities
usually contain detritus from tumor material, old or fresh
blood, mucus, and so on.

The infiltrating form. This form is very common. Sepa-
rate nodules, large and small, are rare. The tumor, usually
starting from a bronchus, penetrates the bronchial wall and
infiltrates the lung along the bronchial as well as the venous,
arterial, lymphatic, and even nerve ramifications.^ This
type is subject to many variations, according as the infiltra-
tion happens to proliferate mainly along the preformed track
of the bronchial ramifications or extends down to the root of
the lung, involving not only larger bronchi but also the bron-
chial, tracheal, and mediastinal glands. It thus forms, besides
extensive pulmonary infiltrations, considerable masses of
tumor at the root which, in their effect upon larger bronchi,
trachea, large vessels, and other mediastinal organs, cause
bronchiectatic dilatations, atelectatic areas, even gangrene,
in the lungs, and all those symptoms, to be discussed later,
which pertain to intra- thoracic growths in general. ^

There is another type of infiltrating tumor affecting only
a portion of a lobe. This starts as a rule from smaller bronchi
or bronchioli; the infiltration is sharply defined against the
normal lung tissue, and is so dense that within the region
of the tumor scarcely any lung tissue can be found. The
entire area is taken up by tumor in which only a few arteries
and veins and some slight dilated bronchi are visible.'

In Plate 2 the destruction of almost the entire lung, from
top to bottom, is well shown. There is little healthy lung
tissue, for nearly the entire lung is gone and the pulmo-
nary tissue replaced by tumor, at first creeping along and
» Stilling, Table I, No. 310. * Conf. Frontispiece. » Plate 1.

42 PRIMARY MALIGNANT GROWTHS OF THE LUNG

infiltrating the lung tissue, then degenerating and breaking
down iato cavities, etc., as described.

The gross forms thus far described apply in general only
to carcinoma of the lungs. The rare cases of sarcoma
may assume similar macroscopic forms and it will then
become difficult to distinguish sarcoma from carcinoma with-
out the aid of the microscope. There is one gross form,
however, that is, to all intents and purposes, pecuUar to
sarcoma. This form appears as very large tumors with
fairly homogeneous structure, sometimes containing cavities,
but comparatively rarely, and never when the tumor is a
lymphosarcoma. These growths may become so large as to
occupy the entire half, or more, of the chest. That portion
of the lung which is not destroyed and replaced by tumor
remains as a mere shell around this growth. Heart, dia-
phragm, mediastinal contents may be extensively displaced.

This very brief and necessarily incomplete sketch of the
mere gross appearances will suffice to show how varied and
comphcated, how difficult of interpretation, are the post-
mortem pictures presented by lung tumors. Sometimes
the picture as seen by the naked eye cannot be recognized
as tumor at all, and the lesions as shown at autopsy will
be interpreted as inflammatory or degenerative processes, —
for instance, as chronic, indurative, or pneumonic lesions.
It follows from this that at every autopsy, even at those
where there is no reason to suspect the presence of tumor, a
microscopic examination according to modern methods is
necessary for every portion of the lungs that does not appear
absolutely sound and healthy.

Passing from the macroscopic to the microscopic study
of primary maUgnant neoplasms of the limg, manifold
difficulties in determining the histological structure of the
tumor, its interpretation and classification, are encountered.
As the simpler group of these tumors, and presenting fewer
of these difficulties, sarcoma will be first discussed. Hertz ^
goes so far as to deny the existence of primary sarcoma of the
lung, claiming that every sarcoma found in that organ is

* Neubildungen der Lungen in Ziemssens Handbuch, 1874, Vol. 5.

PATHOLOGY 43

secondary. It must be admitted that primary sarcoma of
the lung is a great rarity. The writer has not had the
good fortune to observe a single case. Nevertheless, it has
been attempted here to show that the relation of primary
sarcoma of the limg to primary carcinoma of that organ does
not differ from the relation which sarcoma bears to carcinoma
in general.^ This conclusion is based on a collection of ninety-
four cases from the hterature on the subject, ninety of which
have been listed in Table II. It is quite possible that a num-
ber of those set down as doubtful in Table III are genuine
sarcoma. It is possible also, and very probable, that a
great many cases have not been recognized and therefore not
recorded. 2 As more attention is paid to this subject, reports
of cases are pubhshed in greater number than would have
been thought possible some years ago. It would have been
easy to increase the number of cases on Table II to more
than one hundred. All this shows that the beUef in the
extreme rarity of sarcoma has been somewhat exaggerated.

It has been shown above that the gross pictures presented
by sarcoma may differ so slightly from those offered by
carcinoma that microscopic examination alone would serve
to differentiate between the two. It may, however, be said
roughly that sarcoma has a greater tendency to spread
toward the root of the lung, and involve from there the
mediastinal lymph nodes and other organs, than has carci-
noma. Melanotic sarcoma is extremely rare, — there is, in
fact, some doubt in the writer's mind that it occurs at all.
The dark anthracotic pigmentation of lungs and bronchial
glands, pathologically more prominent perhaps, may erro-
neously lead to the suspicion of melanosis. The very large
and massive tumors occupying a great portion of the chest
have just been referred to. They are occasionally subject

1 According to Williams (loc. cit., p. 377), 54.5% of all tumors are car-
cinoma, 9.4% sarcoma, 24.7% non-malignant, and 11.4% cysts. These
figures corroborate the above statement.

2 A quotation from Menetrier (Lubin, These de Paris, 1909, Contributions
k I'Etude du Sarcome primitif du Poumon) seems apt enough in this connec-
tion: "Le cancer n'est pas une forme morbide primitive; c'est un aboutissant
d'etats pathologiques multiples, anterieurs et preparatoires."

44 PRIMARY MALIGNANT GROWTHS OF THE LUNG

to osseous and especially to calcareous degeneration.^ A
scrutiny of Table II shows that about half of the cases
tabulated are of this massive type. Between these and the
more infiltrating forms there are, of course, all manner of
transitions. An especially interesting case came to hand
after the Tables were finished. In this case the entire left
half of the chest was filled by a voluminous mass, dislocating
the heart, impinging on the right lung, and depressing the
liver. The left lung was almost completely replaced by a
huge tumor which pushed the remnants of the pulmonary
tissue upward. The tumor contained a cavity in the midst
of soft tumor material. The duration of the disease was
almost three and a half years. ^ A most interesting case,
also, is that reported^ of a male thirty-three years old, who
entered the hospital in July, 1896. He had been sick since
the previous December with cough, haemoptyses, pains in
right chest, and in addition bronzed skin and bluish sclerse.
In February, 1896, he was seized with a severe pain in the
right leg, especially in the knee, which lasted until death.
The entire right side was more painful than the left; no pig-
mentation in the mouth; percussion absolutely flat over entire
right anterior chest, and resistance much greater than normal;
some cavernous breathing below the right clavicle, otherwise
absolute silence over the whole right posterior lung; sputum
contained nothing characteristic. The autopsy showed an
enormous sarcoma of the right lung, many metastases of
liver, pancreas, etc. Microscopically, a giant celled sarcoma
of mixed type. A diagnosis of primary tumor of the lung
had been made during life, but at autopsy the authors
were inclined to consider the lung tumor secondary and
the tumor in the femur as primary; in the first place on
account of its microscopic structure, — the mixed giant
celled sarcoma, — the giant cell being more common in

1 Chiari, Table III, No. 4.

2 Heilbron et Sezary, Sarcome primitif du poiimon, Bull, et Mem. de la Soc.
Anatom. de Paris, Ann^e 85, No. 7, p. 758.

3 Packard and Steele, Case of Sarcoma of the Lungs, with symptoms of
Addison's disease with involvement of suprarenal capsules. Med. News,
1897, No. 11.

PATHOLOGY 45

bone; furthermore, the advanced condition of degeneration
in the femur beyond that of the lung. For this reason the
authors claim the tumor in the lung as secondary. This
may be correct, but the true facts cannot be obtained with
certainty. If it is secondary in the lungs, we have the very
unusual, as far as the writer knows, the unique, occurrence
of a secondary sarcomatous deposit involving only a single
lung and assuming such huge proportions as almost to occupy
the entire lung. It might be interesting to refer here also to
a publication by Eckersdorff.^ According to his statistics
1.5 per mille of all autopsies are primary sarcoma of the
lungs. Eckersdorff finds up to the year 1908 only four
cases of primary sarcoma of the lungs. He publishes two
cases, one of a man fifty years old living rather a wild life.
In November, 1902, in joke, a friend gave him a blow
between the shoulder-blades which led to a strong desire
to urinate. Next day he felt still much affected, but on
second day entirely well again. Soon thereafter he began
to be hoarse, had pains in region of heart and intermittency
of pulse. The most interesting part of the later history
is the rapid change when, after considerable dyspnoea,
irregular and rapid pulse, urine without albumen, enor-
mous thirst, the patient would suddenly get better. It
was not until late in the course of the disease that total
dulness of left lung with abolished breathing sounds was
discovered. This dulness disappeared quickly with the
exception of one place. Later on there was a sudden dis-
appearance of the pains. Death February 7th in collapse.
The diagnosis during life was: probable neoplasm in the
lung. The anatomical diagnosis, an annular carcinoma
of the left main bronchus with obstruction of this and the
formation of metastatic deposits in the lymph nodes and
on the heart, oedoema of both lungs, pneumonia of the left
lower lobe, and dilatation of both ventricles of the heart.
Microscopical examination showed that it was not a car-
cinoma, but a sarcoma of small round cell type. The

' Zwei Falle von primarem Sarkom der Lunge, Centralbl. f. allg. Path.,
Vol. 17, 1906, p. 355.

46 PRIT^IARY MALIGNANT GROWTHS OF THE LUNG

histogenesis cannot with certainty be determined. The
author thinks that the connective tissue of the bronchial
mucosa is the place of origin. He does not express a
positive opinion as to the causal effect of the blow. In
a second case the origin is referred to the interalveolar
septa. The author expresses the hope that in future the
sputum may be studied more carefully in such cases.

Another case which appeared after the Tables were finished
may be mentioned here, though not a sarcoma, the interest-
ing feature of it being the observation of the blood. Haemo-
globin is not mentioned, but in the first blood count the
red cells are reduced to 3,886,100 and the leucocytes are
increased to 19,840, of which the polynuclears are seventy-
nine per cent. A second blood count also does not give
the haemoglobin. The red cells have dropped down to
2,926,400, the whites have increased to 24,800, and the poly-
nuclears are now eighty-six per cent. A large tumor is
found with cavities supposed to involve the larger bronchi
and the hilus. The microscopical analysis shows a cancroid.
Origin from the bronchus is nevertheless assumed.

The frequent occurrence of primary sarcoma of the lungs
in the form of huge and ponderous tumors is also corrob-
orated by Duran.i Schech^ states that when in the right
lung, the favorite seat of the tumor is the upper lobe, while
in the left lung the favorite seat of tumor is the lower lobe,
and that he has seen the tumor primary in both lungs only
twice. Looking over Table II in regard to this point, one
will find that there is no such difference, but that tumor in
the right upper or left lower lobe, and the converse, occurs
with equal frequency. There are five cases cited in the
Table where both lungs are affected. The duration of
sarcoma of the lungs does not seem to differ very materially
from that of carcinoma. There are fifty-two cases out of the
ninety in Table II from which some approximation as to
their possible duration may be reached. Among these fifty-
two^ the shortest period of duration is one month and the

^ Du sarcome primitif du poumon, Th^se de Paris, 1893.
« Table II, No. 78.

PATHOLOGY 47

longest six years, the average being about four and a half
months, as compared to that of carcinoma, the average for
which is two and a third months. It is evident that these
averages have no real significance, and the only legitimate
deduction from the figures is that primary carcinoma and
sarcoma of the lungs are of indefinite duration, running at
times a very rapid course and again assuming the character
of chronic disease and lasting for many years. ^

The histology of primary sarcoma of the lungs offers in
the main nothing peculiar or characteristic, but practically
corresponds with the histology of sarcoma of other organs.
It has been said^ that the spindle cells occur more frequently
than any other type of cell. Examination of Table II in
regard to this point shows only sixty-eight cases available,
as in the remaining twenty-three there was no clear state-
ment as to the character of the cells. Out of these sixty-
eight cases just half were of the typical uncomplicated
round celled variety, fourteen only were spindle celled,
seven uncomplicated lympho-sarcoma, and there were also
a few mixed tumors, such as lympho-sarcoma with small
round cells, with spindle cells, etc. It seems, therefore, that
round celled, and not spindle celled, sarcomata are by far
the most frequent. Occasionally, giant cells are found.^
There are found, also, the usual combinations, such as
myxo-sarcoma, fibro-sarcoma, and others; various degenera-
tions, as mucoid, colloid, more frequently fatty, and also
calcareous and osseous, attributable principally to the
stroma; occasionally there are cystic forms.

The histogenesis is still obscure. It seems certain that
a great many of the pulmonary sarcomata take their origin
from the root of the lung, probably in one or the other of the
smaller or smallest of the peribronchial glands, growing from
there, as mentioned before, along the track of the bron-
chi, and at an early period penetrating a larger or smaller

^ For further details regarding duration of primary sarcoma of limgs, see
Appendix B.

* Schech, loc. cit.

' Packard and Steele, loc. cit. Also Colomiatti, Table II, No. 14. Also
Klemm, Table IV, No. 10.

48 PMIvLmY MALIGNANT GROWTHS OF THE LUNG

bronchus, obstructing it, and thus continuing in its course
through the lungs, the tissue of which it destroys on its
way. It may also, it is said, penetrate through the pores
of the septa directly into the alveoles. The large massive
tumors almost invariably start at the hilus. It is assmned
by many, though not yet conceded by all, that sarcoma may
develop from the interalveolar septa in the lung itself. The
septa, at one or several spots becoming sarcomatous, may
compress the pulmonary alveoles and fill with tumor material
what is left of the air-vesicles, thus forming nodules of vary-
ing size which, again merging into similar nodules, can form
considerable tumors. The lung tissue in the immediate en-
vironment of these nodular tumors is usually quite healthy,
or evidences only minor changes. Microscopic examination
may show remains of septa or the latter may have been de-
stroyed altogether. As a rule there is no open communication
with the bronchus, but bronchial remnants are seen within
the tumor. In some instances the sarcomatous tissue does
not completely destroy the septa, so that the alveolar struc-
ture in some places at least remains distinctly visible. The
air-vesicles are then filled with a mass of polymorphous
cells which, according to the individual bias of the observer,
may pass either for epitheUal cells or for deformed sarcoma
(round) cells or for endothelial cells. The dispute concerning
endothelium will be touched upon later. For the present
it may be said that some authors consider the endothelium
to play a considerable role in the histology of sarcoma, and
Burkhardt,^ after extensive researches, thinks that sarcoma
and endothelioma are not to be separated from each other,
inasmuch as every sarcoma, besides the proliferating cells
of the connective tissue, contains a greater or less proportion
of endothelia of the lymph spaces as well as adventitia cells.
All sarcoma are, therefore, according to him, more or less
endothelioma, and only according as the connective tissue
cells or the endothelia react stronger do the various types
stand out. This is, of course, a very extreme point of view

^ Sarkome und Endotheliome nach ihrem path.-anatom. und klin. Ver-
halten, Bnins Beitr. z. klin. Chir. 36, 1902.

PATHOLOGY 49

and will have to be discussed later when endothelioma
is touched upon. The microscopic picture often speaks
for this theory, as it presents distinct alveolar structure
with much enlarged septa consisting of spindle cells and
alveoles filled with polymorphous cells. It is this type of
tumor that probably comes under the head of what Virchow
termed carcinoma sarcomatodes.^ The case of Weichselbaum ^
seems to be a true adeno-sarcoma. Is it not possible that
this kind of tumor resembles those produced experimentally
by Ehrlich and his school, in which the stroma of a carcinoma
was ultimately converted into genuine spindle or round
celled sarcoma?

Carcinoma. The epithelium found in the lungs (lungs
being taken in the broader sense and including the bronchi)
consists of cylindrical epithelium, cihated as well as not
cihated. The ciliated cells form the hning of the mucous
membrane of the larger bronchial tubes. As with continued
dichotomous division the branches of the bronchial tree be-
come smaller, so the high ciliated cells become lower, the
cilia gradually disappear, and the very smallest bronchioles
are simply lined by a small, low, cuboid epithelium without
cilia. The bronchial epithelium in the minutest bronchioles
is by gradual transformation changed into the respiratory
and alveolar epithelimn. In the adult this consists of
fiat, squamous cells resembling endothelium. They line
the septa and the pulmonary alveoli. The endothelium
itself, those cells which form the inner coating of the lymph
vessels and spaces, must be presently considered somewhat
more in detail, as it is still a subject of dispute. Cyhndrical
epithelium is also found in the bronchial mucous glands.
This has no cilia and differs in no way from the ordinary
cylindrical cell as found in glands.

Considering only the very limited group of cells that
contribute to the structure and formation of the carcinoma
of the lung, it is often surprisingly difficult to distinguish
the kind of epithelial cells that make up the tumor, and its

^ Bohme, M., Primares Sarco-Carcinom der Pleura, Virchows Archiv.,
Vol. 81, 1880, p. 181. 2 Table III, No. 94.

50 PRIMARY MALIGNANT GROWTHS OF THE LUNG

structural peculiarities, and to understand the histogenesis.
The enormous plasticity of the epithelium, the influence
which territorial hmitations, intense proliferation, pressure
upon each other, and various other intra- and extra-cellular
changes bring to bear upon the cells, — all these features
conspicuously increase the difficulties. It may really
appear at times as if there were no specific kinds of epithe-
lium, but that the epithelial cell, according to merely
extrinsic conditions, might assume any form, cylindrical
cells being transformed into pavement cells, pavement
cells into horny pearls, etc. One is frequently at a loss to
decide whether, in the section before him, the cells are of
epithelial or connective tissue origin, whether it is a carci-
noma or a sarcoma. Frankel, in the discussion of Simmond's
paper, ^ states emphatically that great difiiculty is often
experienced in distinguishing between carcinoma and
sarcoma, owing, on the one hand, to the alveolar structure
of the lung simulating carcinoma, and on the other hand to
the almost limitless proliferation and change of form of the
epithelia suggesting sarcoma. A good example of this is
shown in Plate 3. Here the cells are so crowded, the prolif-
eration is so rapid, that it would be impossible at the spot
photographed to make any other diagnosis than that of a
small round-celled sarcoma. No one would easily believe
that these cells are mere transformations of epithelial cells
and that the tumor is a true carcinoma. Plate 4 shows the
same section with a higher power. One sees a great variety
of polymorphous cells, some of which resemble epithelial,
others sarcoma cells. In one spot a mitosis is plainly to be
seen. Plate 5 is a section of the same tumor from another
place, photographed with a moderate magnification, which
plainly demonstrates the alveolar structure, the typical
stroma, and in several places undoubted epithelial cells.
There can be no hesitancy in calling this tumor a carci-
noma. Plate 6 is a section from the kidney of the same
patient, photographed with high power and showing most

^ liber die Histologie des prim. Lungenkrebses, Miin. Med. Woch,, 1896,
p. 189.

PATHOLOGY 51

beautifully a few undoubted epithelial cells just after their
entrance into Bowman's Capsule. This picture may serve
to remove all possible doubt as to the true natiire of the
tumor.

The various well-known types of carcinoma are all repre-
sented. The carcinoma simplex. Plate 7 is a good illustra-
tion of this. The alveolar structure is very plain, the alveoles
varying in size, lined with cuboid or cylindrical cells and
filled with polymorphous cells jumbled together, compressed
out of shape and partly degenerated (horny, mucoid, colloid,
fatty degeneration, etc., are frequently met with). The
stroma is usually rich in cells and here and there a lymph
space filled with epithelial cells is seen. It is very interest-
ing to note in the picture a tolerably large alveole projecting
its epithelial material directly into a lymph vessel. Plate 8
shows the typical glandular carcinoma without any distinc-
tive features, and consisting mostly of flat and cuboidal
epithelial cells with very little stroma. In this section there
is nothing to suggest the origin of the tumor from the lung.
Plate 9 shows the same form of carcinoma with smaller and
more plexiform alveolar structure, more voluminous and
firmer interstitial tissue, and a very plain demonstration of
the infiltration of lymph vessels and spaces from the alveolar
contents. In Plate 10 is shown a good example of a can-
croid with the characteristic horny epithehal pearls. The
basilar lining of cuboid cells is in this section not very
plain.

The cylindrical celled carcinoma. Plate 11. The cells are
not ciliated. The alveolar structure is evident, the alveoles
varying in size. The larger ones are about the size of a
moderately large bronchus, and it is obvious that they are
formed by the confluence of a number of smaller alveoles.
The contents of these larger alveolar spaces, sometimes sug-
gesting small cavities, consist of cellular and mucous detritus
and scattered epithelial cells in various stages of degenera-
tion. The stroma between the alveoles generally consists of
rather soft connective tissue containing moderately abun-
dant connective tissue cells. This form of carcinoma, occur-

52 PRIMARY MALIGNANT GROWTHS OF THE LUNG

ring as it does quite frequently, is considered by many
pathologists to be the typical, if not the only form, in
which carcinoma occurs in the lungs. It is demonstrable
that this type of tumor develops from the cells of the
bronchial mucous glands. That this is so was first shown
by Langhans,^ whose views were widely accepted. ^ In
Plate 12 there is seen very clearly to the right of the pic-
ture a dilated bronchus with mucoid detritus in its interior
and a partially detached epithelial lining. In the middle of
the picture are shown the bronchial epithelial glands, the
majority of them unchanged, others just at the beginning
of carcinomatous proliferation. Toward the left are some
alveoles lined with cylindrical cells and the transition from
proliferating bronchial mucous glands to carcinomatous
alveoles is clearly perceptible. Plate 13 illustrates similar
conditions. The bronchial cartilage is in parts destroyed
and there are similar carcinomatous degenerations as in the
preceding figure. Some of the alveoles, evidently originat-
ing from degenerated bronchial mucous glands, contain carci-
nomatous epithelium, not typically glandular, but exhibiting
the usual character of pavement epithelium.

Carcinoma may also develop from the surface epithelium
of the bronchi. It is still a matter of some dispute what
kind of cells are characteristic of this form of carcinoma.
It is thought by competent authorities that the surface
epithelium of the bronchi develops a carcinoma of alveolar
structure with polymorphous and polyedric cells that are,
in the great majority of cases flat, but sometimes varying
numbers of cylindrical cells are mingled with them. Such
forms of carcinoma are exemplified by Plates 8 and 9. It
was contended by some^ that the carcinoma just described
might develop from the bronchial mucous membrane, but
might also take its origin from the flat epithelium of the
pulmonary alveoles. This contention caused considerable

1 Virch. Arch., Vol. 53, 1871, p. 470.

2 Chiari, Table I, No. 51; Ebstein, Table I, No. 75; Stilling, Table I, No.
310, and others.

3 Ehrich, Table I, No. 77, and others.

PATHOLOGY 53

discord among the few pathologists who studied the subject.
A number of these without hesitation considered every pul-
monary carcinoma, where they found fiat polyedral epithe-
lium, as necessarily derived from the alveolar cells. A
little closer study showed the untenable character of these
theories. It is unnecessary to enter into all the details of
the discussion. Some considered the flat epithelium in
pulmonary carcinoma extremely rare, others considered it
very frequent. Frohhch,^ for instance, found it twelve
times among sixteen cases. According to the statistics of
Watsuji,2 32.2% of all pulmonary carcinomata are of the
pavement cell variety. There is, however, no evidence that
these carcinomata develop from the pulmonary alveoles.
On the contrary there is considerable evidence against the
supposition. It is now held that carcinoma starting from
the pulmonary alveoles is extremely rare, and some go so
far as to deny its existence altogether. Marchand and his
pupils ^ succeeded in demonstrating beyond doubt a tumor
starting from the alveolar respiratory epitheUum. The
tumor in question would hardly be recognized as tumor by
the naked eye, but rather suggested the opaque and some-
what translucent tissues as they occur in chronic broncho-
pneumonia, and the structure as shown by the microscope
was a great siuprise. It was found that the tumor was
made up of cylindrical cells with more or less of a papillary
arrangement. As the respiratory epithelium in the embryo
is of the cylindrical type, the occiu-rence of cylindrical cells
in these growths is not surprising. The tumor is probably
congenital. Plate 14 shows a section of this sort of tumor,
in which remnants of alveolar structure, with somewhat
irregular but nevertheless recognizable high cylindrical
cells, can still be traced. There are perfectly clear patches
showing papillary arrangement.

Neglecting in this place all further detail, it may be
briefly stated that it is at present the common consensus of
opinion, and probably justly so, that the great majority of

1 Table I, No. 88. * Zeitschr. f. Krebsforsch., Vol. I, p. 445.

* Ejretschmer, loc. cit.

54 PRIMARY MALIGNANT GROWTHS OF THE LUNG

primary carcinomata of the lungs develop from the bronchi,
and that a cancer of the lung is, taken strictly, a bronchial
carcinoma; that, on the other hand, a carcinoma starting
from lung tissue itself occurs, but is extremely rare, and
is built up, not of flat, but of cylindrical epithelium.

CHAPTER VI

PATHOLOGY (Continued)

\ NY attempt to work out the histogenesis of lung tumors
"^~*- leads at once to troublesome questions concerning
epithelium, metaplasia, and other fundamental problems
about which there exist great differences of opinion in the
pathological world. It may be said at once that it is gen-
erally impossible to determine the histogenesis of a fully
developed lung tumor and it rarely or never happens that
we meet with a tumor so small that its very beginnings can
be clearly seen. Even the close study of the growing edges
of the tumor will give no satisfaction, and any certainty
with regard to the histogenetic origin of the majority of lung
tumors must, for the present at least, be given up as hope-
less. Turning to epithelium, it is at this moment practically
impossible to say what "epitheUum" really means and what
its relations are to other kinds of cells, especially to endo-
thehum. The literature on the subject of endothelium and
its relation to tumors, as well as to acute and chronic inflam-
mations in adult tissue and its embryonal history, is really
enormous, and no attempt at even a sketch can be made
here. The work of Borst^ in his large treatise on tumors,
and his several other separate publications, ^ and the critical
compilations of Monckeberg,' go deeply into the question
of endothelioma, while Volkmann,^ and before him Kolaczek,^
have done fundamental work in the study of these tumors.
Leaving this mass of literature to those specially interested,
it is important to arrive, at the very beginning, at some un-

^ Lehre von den Geschwiilsten, Wiesbaden, 1902.
2 Das Verhalten der Endothelien, Wurzburg, 1897, and others.
' Lubarsch, Ergebnisse, 10 Jahrg., Wiesbaden, 1906.
* Deut. Z'tschrift f. Chir., Vol. XLI, 1895.
6 Deut. Z'tschrift f. Chir., Vols. IX and XIII, 1878 and 1880.

56 PRIMARY MALIGNANT GROWTHS OF THE LUNG

derstanding of the nature of epithelial cells. It is generally
accepted that epithelium assumes various forms differing in
morphological structure and in physiological function. The
forms recognized by all are: (1) cylindrical epithelium, which
is differentiated into several species : (a) endowed with cilia
upon which certain physiological motor functions depend,
and (6) without cilia, dispersed in a single layer or in several
strata, serving as an inner coating to numerous hollow
organs, and lastly, (c) glandular cylindrical epithelium, to
which are allotted duties of secretion and excretion; (2) fiat,
squamous, or pavement epithelium, arranged either in single
layers or; in numerous strata and modified in its morpho-
logical structure according to the physiological function
which it is called upon to perform. The lining of numerous
internal organs consists of this type of epithelium. The
epidermis which protects the surface of the entire common
integument is in the main built up of such cells, specially
differentiated as to their structure and chemical constitu-
tion (kerato-hyalin, intra-cellular structure, and protoplas-
matic bridges). No further detailed description of epithelial
cells is necessary. Until very recently it was accepted as
a fact that the three germinal layers were the dominant
factors in the histogenesis of all the tissues and organs in
intra- as well as extra-uterine life. All the epithelium that
was needed for the viscera of the chest and abdomen was
supposed to be furnished by the entoderm. The epithelium
of the common integument and of several other organs
closely connected with the outer surface is referred to the
ectoderm. There is besides this a certain class of flat cells
bearing nearly all the hallmarks of genuine flat epithelial
cells, which are universally found in the body as a lining
of the great lymphatic cavities (pleura, peritoneum, etc.).
The inner coat of the arteries and veins and the perivas-
cular lymph spaces, as well as all lymph spaces throughout
the body, are lined with this peculiar epithelium. Its origin
is said to be from the mesoderm, the mesoderm being the
third germinal layer, from which the fibrous and connective
tissue, the bones, cartilages, elastic fibres, etc., — aptly

PATHOLOGY (Continued) 57

called by the Germans ''Stiitzgewebe," — are said to origi-
nate. These cells just mentioned as coming from the meso-
derm could not be classified as genuine epithelium and
were therefore called by His endothelium. They showed,
on the one hand, close connection with the connective tissue
cells, with which, indeed, they have much in common, espe-
cially the property of forming fibro-plastic cells. There
are many tumors that are supposed to be developed from
the endothelium and are therefore named endothelioma.
These are usually non-malignant, but there are also malig-
nant forms of endothelioma. Borst and his followers have
also not infrequently found endothelioma as a primary
malignant neoplasm in the lung. The writer himself^ was
at one time convinced of the occurrence of primary malig-
nant endothelioma in the lungs, but has since been forced
to change his opinion.

At the present writing opinions as to the embryonal
development of the so-called endothelium are extremely
perplexing. The doctrine that the endothelium, as well
as the connective, osseous, and other specific elements,
are derived from the mesoderm, is becoming more and
more discredited. Hertwig^ derives the mesoderm from
the primary entoderm, and according to him, at a very
early stage independent mesenchym germinal cells emigrate
and proliferate in the spaces between the ento- and ecto-
derm, and thus form the basis for the development of the
connective tissue substances and blood. Schultze,^ on the
other hand, derives the mesoderm from the ectoderm, and
according to him nearly all the cells of the mesoderm possess
considerable mobiUty of their own, so that they wander
through all the organs developed from either of the germinal
layers. It will be seen by these two quotations how unsatis-
factory as yet the embryonal history of endothelium is. It
will also be seen that embryology is tending more and more

^ I. Adler, Remarks on Primaxy Endothelioma of the Lung, Pleura, etc.,
Journal of Medical Research, VI, 1901.

* O. Hertwig, Lehrbuch d. Entwicklungsgeschichte, 1896.

* O. Schultze, Grundriss der Entwicklungsgeschichte, Leipzig, 1896.

58 PRIMARY MALIGNANT GROWTHS OF THE LUNG

toward giving up the mesoderm as a primary germinal layer
and is depending more and more upon the ento- and ecto-
derm, with only secondary and varying assistance from a
secondary mesoderm. It is impossible to go further into
details. Let it suffice to say that at present there is little
doubt, though the various workers on this subject have not
arrived at a uniform opinion as to what cells should be classed
as endothelium and what as epithelium, that there is a form
of cell which may rightly be called endothelium, which occu-
pies a unique position in so far that it lines the banks of
seas and streams of fluid, where it is not only acting as a
mere mechanical agent, but has certain other physiological
properties which will be touched upon presently.

Suppose the endothelium to be derived from the meso-
derm and to be an integral part of the connective tissue
system, it follows, and rather absurdly, that a tumor pos-
sessing alveolar structure and cells, not to be distinguished
from the true epithelial (carcinomatous) cells, — a neoplasm,
in short, that acts altogether like a carcinoma, — must be
classed among the malignant connective tissue tumors; in
other words, must be called a sarcoma. Thus Remak,
Thiersch, Billroth, and Waldeyer classed as sarcoma all
tumors that develop in localities where normally no epithe-
lium is found. This may in part be responsible for such
designations as adeno-sarcoma, alveolar carcinoma, lympho-
sarcoma, etc. Koster^ does not employ the term ''endo-
thelioma," but assumes that all carcinomata take origin
from the lymph vessels. Of late the opinion is gaining
ground that the intimate structure of the tumor is not
dependent upon certain phases of embryological develop-
ment nor upon the morphological relations of the three
germinal layers. It is held that whatever tumor possesses
carcinomatous structure and behaves clinically as a carci-
noma is a carcinoma, no matter whether its component
epithelial constituents be derived from the mesoderm, the
entoderm, or the ectoderm. In other words, it is said
that, .while the germinal layers are of utmost importance

1 Die Entwicklung der Carcinome und Sarcome, Wiirzburg, 1869.

PATHOLOGY (Continued) 59

as regards differentiation, topography, and ultimate devel-
opment and function of the tissues, their influence to a
great extent ceases when the organism is complete and the
foetus is fully developed. Extra-uterine pathology should
not be tyrannized over by embryology.^ Klaatsch^ also
points out that the concept of a mesoderm is gradually
disappearing and that the ectoderm is of paramount
importance. He shows, moreover, the necessity of being
guided in one's judgment more by the physiological
requirements and functions than by the merely morpho-
logical and embryological point of view. He demonstrates
convincingly that the morphological character of cells may
be changed to a considerable extent, consequent upon changes
in the surrounding tissues, especially when gaps in the con-
tinuity of the tissues are formed. He is totally opposed to
a classification of tumors in their relations to the three
germinal layers. It is to be noted that both functionally
and physiologically the endothelium appears closely related
to typical epithelium.

It is not necessary to go into all the finer distinctions
between endothelium and epithelium. It is best, in the
opinion of the writer, to agree with Borst that there are
tumors undoubtedly taking origin from endothelium, and
as the endothelium occupies a peculiar position, on the
one hand appropriating to itself some of the functions of
epithelium,^ on the other hand being intimately associated
with connective tissue, even forming fibro-plastic cells, it
is best to call these tumors by the special name of endothe-
Uomata. That there are malignant endotheliomata, we
cannot doubt, such perhaps as the much discussed primary
cancer of the pleura, concerning which there is still no unity
of opinion and a lack of clear and sharp definition. This is

^ Marchand, Uber die Beziehungen der path. Anatomie zur Entwicklungs-
geschichte, besonders der Keimblattlehre, Verhand. Deut. Path. Ges., II,
1900, pp. 38 ff.

2 t)ber den jetzigen Stand der Keimblattfrage mit Rucksicht auf die Patho-
logie, Miinch. Med. Woch., 1899, N. 6, p. 169.

^ Haidenhain, Verhand. des X. internat. Congresses, Berl. 1891, Vol. II;
also Archiv. f. Physiol, v. Pfltiger, Vol. 49, 1891, and Vol. 56, 1894; also Orlow,
Recklinghausen, Adler and Meltzer, Meltzer, and others.

60 PRIMARY MALIGNANT GROWTHS OF THE LUNG

shown by the various names, as for instance ''lymphangitis
carcinomatodes " ^ or "lymphangitis prolif erans. " ^ As to
the lung, however, the writer has not as yet been so fortunate
as to be able to diagnosticate an endothehoma of the lung,
though Borst and his pupils and others^ have published a
number of cases.

If one beheves, as does the writer, that these malignant
tumors, carcinoma and others, grow not peripherically,
but centrally, out of themselves, as it were,'* then the
mere fact of the lymph spaces and lymph vessels at the
periphery of the growth being filled with endotheUal cells

1 Schottelius, Table I, No. 289.

2 A. Frankel, tlber primaren Endothelkrebs der Pleura, Berl. Klin. Woch.,
1892, 21 and 22. In this connection it might be well to mention the case of
Bostrom (Das Endothelcarcinom, Diss. Erlangen, 1876). It concerns a female
twenty-eight years of age who had complained of no lung symptoms whatever,
but who suffered mainly from the stomach, and the diagnosis of ulcer of the
stomach was made. She died suddenly from profuse gastric hgemorrhage. At
autopsy the ulcer of the stomach was found and carefully examined, by as high
an authority as Zenker, and no trace of anything that could be taken for car-
cinoma was detected. Nevertheless, besides about half a litre of bloody sermn
in both pleural cavities without any adhesions of the lungs, there was extensive
carcinomatous lymphangitis on the pleura of both sides and carcinomatous
infiltration of the bronchial, tracheal, and retroperitoneal glands. Cases of
carcinoma of the stomach with extensive carcinomatous lymphangitis cover-
ing the lungs have been frequently reported (Hilliarie, I'Union m4d., 1874, Nos.
53, 54, and 55; Frantzel, Charite-Annalen, 1878, III, 306; Debove, Gas.
Hebd., 1879, N. 43, p. 688). But in these cases there was usually a con-
spicuous primary carcinomatous nodule to be found in the stomach. In this
case of Bostrom's we have a practically certain assurance that there was
no carcinoma in the stomach. By means of very careful examination, the
bronchial mucous glands, the bronchial and alveolar surface epitheUum could
be positively excluded, and the author, after most painstaking study, by means
of serial sections of both pleura, comes to the conclusion that the pleural affec-
tion has nothing whatever to do with the gastric ulcer, but is an independent
carcinoma of the endotheliima of the pleural lymph vessels.

3 Wack, Ein seltener Fall von primarem Endotheliom der Lunge, Diss.
Wurzburg, 1898; Klemm, "Cber ein primares Endotheliom der Lunge, Diss.
Miinchen, 1905; Bostrom, Endothelcarcinom der Lunge, Diss. Erlangen, 1876;
Cahen, Diss. Wurzburg, 1896; Neelsen, Deut. Arch. Klin. Med., Vol. 31,
p. 375.

* Borrman (Die Entstehung und das Wachstum des Hautcarcinoms, Z. f.
Krebsforsch., II, 1904) is an enthusiastic adherent of imi-central or possibly
multi-central growth of carcinoma. He calls attention justly to the fact that
nobody has ever yet seen the conversion of a normal epithelial cell into a can-
cerous epithelial cell, and as his material consisted of carcinoma of the skin
in its very earliest stages of development, his findings possess considerable
weight.

PATHOLOGY (Continued) 61

means nothing as to histogenesis, while on the other hand
it will never be possible to study a tumor at a stage early
enough to show a possible development of the endothelium
into maUgnant cells. Thus the diagnosis of primary endo-
thelioma of the lungs is at present not possible, and it is
preferable to call these tumors, not endothelioma, or sar-
coma, on purely theoretical grounds, but carcinoma, if they
are built and act like one, and sarcoma imder similar
conditions.

There are many microscopic pictures which are adduced
as characteristic of endothelioma, especially those show-
ing ramifications simulating a network of deep interlacing
meshes, strongly suggesting a system of lymphatics, more or
less completely filled with fiat, endothelial-like cells. Plate
15, taken from the same tumor as Plate 9, shows this rami-
fication. Neither Plate 9 nor Plate 15 can possibly be taken
for an endothelioma, as other parts of the same tumor show
typical carcinoma. In the same way Plate 16 shows very
prettily the injection of the lymph vessels and lymph spaces
with carcinomatous material, but it is from the same tumor
from which Plate 7 is taken, in which was shown the
mechanical injection of cells from a large typical carci-
nomatous alveolus into a lymph vessel, and it is not possi-
ble to prove, with any kind of magnification, that lymph
endothelium was converted into carcinomatous cells.

CHAPTER VII

PATHOLOGY (Continued)

THE aphorism of Bard/ "Omnis cellula e cellula ejusdem
generis," has been mentioned. If each kind of epithe-
lium be considered a specific genus, then, according to him,
cyhndrical epitheHum should produce only cylindrical epi-
thelium; cuboid, or fiat, or horny, should always and under
all conditions produce a similar kind of epithelium. It soon
became evident, however, that histology did not completely
bear out the theory of the strict and hmited production
of cells of a certain character and structure from cells of
identically the same character and structure. A long, and
at this writing still unsettled, discussion has taken place
concerning these questions, which are summarized under
the title of '^ Metaplasia." It is necessary to touch briefly
on some of the problems of metaplasia in order to obtain
a proper notion of certain changes in structure and char-
acter of the cells that occur here and there, perhaps not
infrequently, in lung tumors.

Virchow, as is well known, assigned a very great role to
metaplasia in pathology, which meant for him something
entirely different from what is understood to-day by the
term. He attributed, especially to the connective tissue
cells, all sorts of possible metaplastic changes, deriving
osseous tissue therefrom as well as the epithelial cells of
carcinoma. It is useless to enumerate the multitude of
pathologists who have devoted time and no slight labor
to this question of metaplasia. Opinions differ as to
whether such a process actually exists, and, if it does
exist, what the meaning of the process is. Ribbert defines
metaplasia as a sort of regression, the cells losing their speci-
ficity and attaining a simpler structure, or in other words

1 Loc. cit.
62

PATHOLOGY (Continued) 63

returning to some lower state of differentiation through
which, in the regular course of development, they had
already passed, and this without regaining new properties.
Hansemann speaks of histological accommodation and of
anaplasia as being a lower grade of differentiation along
embryological lines, to which the metaplastic cells return.
It is a mooted point whether this metaplasia of the cells
proceeds under the laws of strict embryonal development
and is ruled by the theory of the three germinal layers. If
this hypothesis were true, then the metaplastic alterations to
which, say, an entodermal epithelial cell is subjected would
result only in such types of cell as normally originated from
the entoderm.

On the other hand, it is maintained that metaplasia is
entirely independent of embryonal influences and that
the alterations in the character of the cell are produced
by mechanical and physical conditions and in a great
measure by causes as yet unknown. Finally, there is a
theory entertained by many that the so-called metaplasia
of cells and tissues, especially when occurring in tumors, is
the outcome of congenitally displaced germinal remnants.^
It is not necessary to go into further details on this point.
For further reference to these questions in regard to tumors
see Lubarsch.2 Most important, and throwing light also on
the metaplasia in tumors, is the work of Schridde.^ Speak-
ing only for lung tumors, and indifferent to what may take
place in other tumors or organs with reference to metaplasia,
it is to be noted that only such cells can justly be considered
as metaplastic cells that reproduce not only the superficial
character of the cells, such as localization, general appear-
ance, etc., but the cell must exhibit the intimate and charac-
teristic structure of the type of cells which is supposed to be
represented. Thus, an ordinary flat epithelium can by no

1 Ernst, Table I, No. 82.

* Lubarsch, Die Metaplasiefrage und ihre Bedeutung fur die Geschwulst-
lehre, Arbeiten aus der path. Anatom. Abteilung des Kgl. Hyg. Institut in
Posen, 1901, N. 305 ff.

' Schridde, Die Entwicklungsgeschichte des menschlichen Speiserohren-
epithels und ihre Bedeutung fur die Metaplasielehre, 1907; Die Ortsfremden
Epithelgewebe des Menschen, Jena, 1909.

64 PRIMARY MALIGNANT GROWTHS OF THE LUNG

means be considered as an epidermal cell unless it shows the
pecuhar structm-e, the fibres, and protoplasmatic bridges
of the latter. A high cuboid or a laterally compressed
flat cell is not converted into a cylindrical cell unless it
shows at least some of the typical characteristics of the
latter, — the nucleus at the base, the colloid, mucoid, or
other secretion, etc. It is reasonable to assume, and seems
to be the result of common experience, that the nearer the
epithelia are related to each other, the more readily they
will interchange in form and structure.^ The transforma-
tions of one sort of epithelium into another, usually of
cylindrical or cuboid epithehum into squamous epithelium,
as has been frequently found in many kinds of inflamma-
tory processes, in granulations, in pneumonias, ^ in the gall
bladder,^ in the urinary bladder, in the uterus, in the pan-
creas,^ and other organs, are well known. They are usually
the results of acute or chronic inflammations. It would
indeed be strange if similar metaplasia of the epithelium
were not also found in the bronchi and in the lungs. Under
purely physiological conditions and under perfectly normal
development, certain epithelial changes in the bronchi are
regularly found. The largest and larger bronchial tubes
are lined with ciUated cylindrical epithehum. In the smaller
orders of the bronchial tubes these cylindrical cells lose their
ciha. In still smaller orders the cells become cuboid, and
finally, and without break in the continuity, the very small-
est bronchioles and the pulmonary alveoles are lined with
flat epitheUal cells. Metaplastic changes in the epithelium
under pathological conditions are shown by the work of
Kitamura,^ who finds in almost every grade of catarrhal

1 Let it be understood that even in the question of metaplasia, the speci-
ficity of cells as postulated by Bard is still maintained to a certain extent.
Metaplasia can take place only among cells embryologically closely related.

2 Conf. the work of Friedlander, tjber Epithelwucherimg und Krebs, Strass-
burg, 1877, 57 S. mit 2 Tafeln.

» Dietz, Virch., Arch., Vol. 164, p. 381.

* Lewisohn, Zwei Seltene Carcinomfalle zugleich ein Beitrag zur Meta-
plasiefrage, Z'tschrift f. Krebsforsch., Ill, 1905, p. 528.

^ Kitamura, Uber secundare Veranderungen der Bronchien und einige
Bemerkungen uber die Frage der Metaplasie., Virch. Arch. 190, 1907, p. 160.

PATHOLOGY (Continued) 65

inflammations of the severer types, and especially in tuber-
culosis, the transformation of single layers of cyhndrical
ciliated cells into cuboid or polygonal cells. He does not
consider this a true metaplasia, but simply a change in form,
a "histological accommodation" in the sense of Hansemann.^
On the other hand he finds genuine stratified epidermal epi-
thelium with typical keratohyalin in the uppermost strata.
This occurs in the large bronchi that are in open communica-
tion with tubercular cavities. Later, islets of this epidermal
epithelium are found. There are many other metaplasias
throughout the bronchial system, such as chalky degenera-
tions and the formation of bone in the bronchial wall, etc.
These metaplasias seem to occur very frequently as phe-
nomena secondary to tuberculosis. In this connection, too,
there is the work of McKenzie.^ His conclusion, after very
careful study of four cases in very young children, — the
oldest only two years old, — is that real genuine metaplasia
exists. Not only chronic inflammatory processes, as Sim-
monds beheves, but also acute inflammations in the lungs
may lead to metaplasia. The existence of such islets of
pavement epithelium in the lungs after acute inflammation
may have some connection with the development of pavement
celled cancer in the lungs. The assumption of dislocated
germinal cells is not needed to explain the development of
pavement epithelium cancer in the lungs.

Eichholz,^ in his very excellent experimental researches
concerning the conversion of the epidermis into mucous mem-
brane, and conversely, is inclined to think that metaplasia
is not to be excluded with certainty, but on the whole it
does not seem likely to him. In most of the cases where
true epidermis was formed it could be demonstrated that it
was due to a proliferation of the epidermis from without.

1 Loc. cit.

2 Ivy McKenzie, Epithelmetaplasie bei Bronchopneumonie, Virch. Arch.
190, p. 351. (Note, by the author. — We know of many cases of conversion
of cyhndrical into pavement epithehum; we know of none as yet of pavement
into cyhndrical epithehum.)

' Eichholz, Experimentelle Untersuchungen iiber Epithelmetaplasie, Lan-
genbecks Arch. f. klin. Chir., Vol. 65, p. 959.
6

66 PRIMARY MALIGNANT GROWTHS OF THE LUNG

Cylindrical epithelium, according to him, is able to produce
epidermis. If, however, epidermis occurs in tissue of cylin-
drical epithelium, it is to be explained either through the
proUferation of the epidermal epithelium from without or by
the assumption of a dislocated embryonal germ.

It is, therefore, not difficult to explain the occurrence of
true cancroid, to use the old name, — that is to say, of
nodules consisting of typical epidermal cells with the charac-
teristic structure and the formation of cancer pearls. It
appears natural, too, according to the views of Kitamura,
that these cases generally occur in connection with tubercu-
losis, as in the cases of Friedlander,^ Perrone,^ Gougerot,'
and a number of others. The tumor either came from with-
out and penetrated through the wall, and thus projected into
the tubercular cavity,* or developed directly from the wall
of the cavity. In the case of Ernst ^ the cancroid took its
origin from the wall of the main bronchus of the right upper
lobe. As from this location no epidermal tissue could
normally be expected, Ernst attributed his tumor to develop-
ment from a germinal remnant. In view of this widespread
instability in the types and forms of the epithelial cells and
the apparent lawlessness with which these transformations
from cylindrical to cuboid and from flat to cylindrical,
from ciliated to non-ciliated, recur, one is tempted to share
with John Marshall ® the belief in a complete anarchy as
the essence of cancerous proliferation. This anarchy Mar-
shall is inclined to attribute to the lack of nerve influence,
no nerves having as yet been demonstrated in any malignant
tumor, with the exception of a very few perivascular nerve
fibrils. According to this view there would be no meaning
in metaplasia and no reversion to embryonal types or
conditions. The process would simply be anarchy, which
might be subdivided into anarchimorphic, anarchibolic,

1 Friedlander, Table I, No. 87.

2 Perrone, Table I, No. 257.

3 Gougerot, Table I, No. 98.

* Perrone.

" Ernst, Table I, No.82.

* Marshall, The Morton Lecture on Cancer and Cancerous Disease, Lancet,
II, 1889, pp. 1045 ff.

PATHOLOGY (Continued) 67

anarchisynthetic forms. Beneke^ does not agree with this
view. According to him the nervous system can only
regulate the forces contained in the cell, and he suggests a
disturbed equilibrium in the relations and proportions of the
cell function as a causal factor. In the writer's opinion all
these facts and theories lead necessarily to the conviction
that epithelium is a highly plastic material, designed to
accommodate itself in manifold ways to the demands which
local, physiological, and pathological conditions require.
The changes thus produced, however, can only take place
among the specific epithelial cells, whether derived from
entoderm, ectoderm, or mesoderm. The divisions into
squamous, epidermal, cylindrical, ciliated, and epithelial
depend upon more or less functional and often unstable
qualities and are employed more for the sake of con-
venience than as a description of the character of the
cells. The numerous studies with reference to the ques-
tion of metaplasia 2 do not appear to give much enlighten-
ment as to tumors, but seem to corroborate the opinion here
upheld. The theory of persisting and abnormally dispersed
germinal centres and remnants, while it cannot be dis-
proven, is not necessary for the explanation of the so-called
metaplastic transformations.^

1 Beneke, Neuere Arbeiten zur Lehre vom Carcinom, Schmidts Jahrbiicher,
1892, pp. 73 £f.

2 Kawamura, Beitrage zur Frage der Epithelmetaplasie, Virch. Arch., Vol.
203, No. 3, 1911.

' Fixtterer, Uber Epithelmetaplasie, Lubarsch-Ostertag, Ergebnisse, IX,
2, p. 706. Simmonds, Munch. Med. Woch., 1898, p. 189. Watsuji, Zeitschr.
f. Krebsforschung, Vol. 1, No. 5, 1904.

CHAPTER VIII
CLINICAL

UNTIL very recently it was the conunon consensus of
medical opinion that the diagnosis of primary carci-
noma or sarcoma of the lung, if it could be made at all, was
one of a more or less high degree of probability, but never
of certainty and precision. Within the last few years, how-
ever, decided advances have been made in our diagnostic
methods, rendering it possible to diagnosticate a timaor of
the lung with nearly as much certainty as the present status
of our diagnostics permits a cancer diagnosis for any other
internal organ of the body. Stokes's remark, speaking of the
diagnosis of primary cancer of the lung, that "though none
of the physical signs of this disease are, separately considered,
peculiar to it, yet the combinations and modes of succession
are not seen in any other affection of the lung,"^ has been
true for nearly a hundred years and has been a source of
stimulation and hope to many. The clinician's ambition
to-day is not, at the conclusion of long and anxious obser-
vation, to make a diagnosis of lung tumor that is merely
probable. His object should be to diagnosticate the tumor
at the earliest possible stage of its development, and with
such accuracy as is needed for the basis of surgical treat-
ment. This, however, is by no means an easy task.

Note. — It will be necessary to refer frequently to the writings of Stokes
(Table III, No. 78), Hughes (Table I, No. 121), Graves (Table III. No. 30),
Frankel (Table I, No. 85), Passler (Table I, No. 241), Leopold (Table I, No.
174), and Lenhartz (Table II, No. 46), and to that most recent and excellent
pubHcation of Wolff (Die Lehre von der Krebskrankheit, Vol. II, Jena, 1911).
In making this general statement of indebtedness, the writer hopes to be ex-
cused from special references to these authors where such reference is deemed
unnecessary.

1 Diseases of the Chest, New Sydenham Society, London, 1882, pp. 420
and 421.

CLINICAL 69

In many cases the diagnosis is impossible because there
are no symptoms pointing to the lungs and the tumor is an
unexpected discovery on the autopsy table. To illustrate
this, some cases may be singled out, — that reported by
Colomiatti'^ and that of Bernouilli.^ The latter was a case
of a female fifty-one years of age, without chnical history
except that she died of peritonitis after operation for um-
bilical hernia. Autopsy was held the day after. A small
round celled sarcoma of the size of a walnut was lodged in
the right upper lobe and evidently had not caused any
symptoms. There were no metastases, not even of a single
gland.

In some cases there are symptoms, but none pointing
toward disease of the lungs, and therefore the observer is
misled. The patient of Beveridge,^ it is true, had a shght
cough and some pressure over the chest, but not sufficient
to interfere with his work. He worked until death, which
came suddenly from haemorrhage of the lungs. Kliiber ^
reports an apparently healthy woman, dying suddenly from
a bum, without any lung symptoms. In the case reported
by Walshe,^ there was no cough, nothing pointing to the
lungs, but the symptoms were exclusively psychic. Davy's
patient^ was healthy until he acquired jaundice and pain
in abdomen; physical examination of lungs was negative,
no symptoms pointing to lungs, no cough, no pain. Degen^
reports a patient healthy and strong; sudden death from
haemorrhage of lungs; no other cUnical symptoms. The
much cited case of McAldowie ^ is that of a child five and a
half months old, — no dyspnoea, no cough, percussion clear
over both lungs.

It is obvious that tumors such as the malignant neoplasms
of the lungs, varying so widely in type and localization,
entering into so many unstable relations with other organs
of the chest and, through metastases, with almost every

1 Table II, No. 14.

2 tlber primare Lungensarkomatose, Diss. Miinchen, 1907.

» Table I, No. 38. « Table I, No. 56.

* Table I, No. 145. ^ Table I, No. 59.

<• Table I, No. 329. s Table III, No. 53.

70 PRIMARY MALIGNANT GROWTHS OF THE LUNG

organ in the body, cannot be expected to present a perma-
nent and characteristic set of symptoms. One is reminded
of Graves/ who, reporting a case of maUgnant disease of the
lungs, probably sarcoma, gives a minute analysis of the
cUnical symptoms and shows how both he and Stokes were
misled. He candidly confesses that he should have made the
proper diagnosis during hfe, but adds, in his characteristic
manner, "I became quite tired of the difficulty of attempt-
ing to explain the phenomena observed and gave up all
further attempts at diagnosis." It may be said in a general
way that the possibility of a clean-cut diagnosis depends
largely upon the anatomical localization of the tumor and
upon the degree of development which the disease has
reached when the patient is presented. It is not probable
that the actual beginning of the blastomic development will
ever be perceived, since it is necessary that the tumor
attain a certain size before it can be recognized. Again, in
the last stages, the clinical picture may be so complicated,
nearly every organ of the body participating in the morbid
process and causing symptoms which almost completely
mask the pulmonary lesions, that the difficulties are greatly
augmented and a diagnosis rendered practically impossible.

There are, however, certain symptoms which are common
to all malignant neoplasms and some which are more or
less peculiar to malignant neoplasms of the lungs, to which
brief attention must be given.

I. Pain. This is frequently not a real, acute pain, but
rather a sense of discomfort and pressure in the chest.
According to Schmidt ^ the pulmonary parenchyma is prob-
ably insensible to pain, therefore the acute or chronic
genuine stabbing pain is brought about when the pleura
participates in the inflammatory processes which are apt
to accompany the progress of the disease. Taking into
account the well-known relations between the two folds of
the pleura and the nerves, — the brachial plexus, intercostal
nerves, phrenic nerve, — and the diaphragm, it is clear that

1 Table III, No. 30.

* Die Schmerzphenomene bei inneren Krankheiten, etc., Wien, 1906.

CLINICAL 71

the pain produced in one place may be referred to localities
quite distant from the point of origin. The pain in the
shoulder and around the clavicle, the neuralgias of the arm,
the intercostal pains along the chest and in the abdomen
and diaphragm, which so often occur both in carcinoma and
in sarcoma, are thus easily explained, and it is understood
that where there is no pain the pleura has evidently not
been involved. Schmidt also points out that a large area
of dulness, without spontaneous or pressure pain, excludes
any inflammatory process of either fold of the pleura and
suggests the possibility of a neoplasm. Figures represent-
ing an approximate estimate of the occurrence of pain in
malignant lung tumors can be obtained from Tables I and II.
In Table I pain is not mentioned in 206 cases out of 374.
This, of course, does not mean that pain was not present,
but merely that any reference to pain was omitted. The
probability therefore is that the cases in which pain was a fea-
ture are much more numerous than would appear from the
Table. In eighteen cases it is distinctly stated that there
was no pain during the entire course of the disease, while pain
is mentioned as present in one hundred and fifty cases. In
Table II, dealing with sarcoma, pain is given as a symptom
at some time during the disease in fifty-two cases, in two
cases only is it distinctly stated that there was no pain
whatever, in six cases there is no clinical history, and pain
is not mentioned in the history of thirty-four cases.

The possible irradiations along various nerve tracts are
illustrated by the case of Demange,^ in which the pain was
constantly referred to the healthy side. In two cases the
pain was mostly abdominal, while in the case of Harris ^
the pain was referred to both sides of the chest. If one
could draw deductions from these figures, it would seem that
sarcoma causes more pain than carcinoma. This result,
however, is probably illusory and caused by the imperfect
statistics.

11. Cough. This complication is one that would natu-
rally be expected in any malady of the lungs, and therefore

1 Table II, No. 17. ^ Table II, No. 33.

72 PRIMARY MALIGNANT GROWTHS OF THE LUNG

in tumors of the lung. Indeed, cough is probably the most
common of all symptoms appertaining to lung tumors, and
there are but few cases in which it is not a factor. A rather
insignificant, but fairly constant, irritating cough, mostly
without expectoration, may be the earliest symptom of
tumor. Where this cough exists and nothing abnormal is
found in the chest, the upper air-passages, oesophagus, etc.,
the possibility of the presence of a lung tumor should, in the
writer's opinion, suggest itself. A case observed by the
writer, which does not appear among the material collected,
may serve to illustrate this rather important point. It con-
cerned a lady of some sixty-odd years, fairly healthy, and so
far as known, without any hereditary strain of malignancy.
She began to cough this same short, hacking cough, without
pain, without expectoration. Both lungs on close examina-
tion gave no indication of anything abnormal and nothing
abnormal could be detected anywhere, except a trifling
pharyngitis. Very gradually some loss of flesh and strength
became apparent, and after several months a very small
area of dulness at the right hilus, together with some fairly
loud cornage, could be made out. The dulness gradually
extended. For some time previous a tumor had been sus-
pected, principally from the cornage, and the diagnosis was
corroborated when the dulness and cornage were also found
at the apex. There was never much expectoration, and no
blood. The emaciation and weakness increased, the area
of dulness on the right lung extended over the entire lower
and middle lobes, with diminished voice and breathing,
secondary plainly palpable nodules appeared, especially in
the hver, accompanied by jaundice, and death from exhaus-
tion took place in about a year from the beginning of the
cough. No autopsy could be obtained, but there is httle
room for doubt that this was a genuine case of carcinoma
of the lung.

Besides this slight hacking cough, accompanied by little or
no distress, all varieties of cough, up to the most violent,
explosive, and harassing forms, are reported. The cough
may, as just mentioned, be an early symptom of the disease;

CLINICAL 73

on the other hand there may be no cough until shortly
before the fatal end. As bronchitis is one of the ordinary
features of the case, the fairly loose cough, accompanied
by large and small mucoid rales, is present in the majority of
cases. If bronchiectatic cavities, or cavities of other origin,
are present, there will probably be attacks of coughing of
an explosive character, discharging large quantities of muco-
purulent or purely purulent expectoration, often mixed with
blood. When the cavities are sufficiently refilled or com-
munication with the bronchus is again restored, these spells
are apt to recur. The distressing, rasping, but usually dry
cough that is caused by compression or irritation of the
larger bronchi and the trachea is often noted. At times this
cough is accompanied by considerable stridor. Schwalbe ^
claims that carcinoma produces very little stridor, if any at
all, but that it occurs in its greatest intensity and most
frequently in sarcoma, and his explanation of this is that
sarcoma gives rise to earlier and more extensive involvement
of the mediastinal organs than carcinoma, thereby exerting
more pressure on the trachea and nerves. This does not,
perhaps, quite correspond with the actual facts, and it can
be seen from the material collected here that carcinoma also
can, and frequently does, involve all the mediastinal organs.
There is, furthermore, the hoarseness, also the well-known
laryngeal cough, both of which usually occur in late stages
of the disease, when either one or both superior larjmgeal
recurrent nerves have become involved and paralyzed. In
Table I cough in its various forms is mentioned in 174 cases,
while in 191 cases it is not mentioned. In nine cases it is
distinctly stated that there was no cough. In Table II cough
is mentioned as a symptom forty-six times; five cases had no
cough, and thirty-nine passed without any mention of it.

III. Sputum. Much more important than the cough, —
in fact, one of the principal signs to be depended upon for
the diagnosis of malignant lung tumors, — is the character
of the sputum. This, however, can only be satisfactory as
the result of close study. It is necessary to bear in mind that

1 Deut. Med. Woch., 1891, No. 45.

74 PRIMARY MALIGNANT GROWTHS OF THE LUNG

a single examination of the sputum will rarely give reliable
results. The ordinary routine examination of the expecto-
ration, such as is the common practice, which consists in a
search for tubercle bacilh or elastic fibres, and at best a
few cells, is entirely insufficient when so delicate a diagnosis
as that of primary lung tumor is the object. It is necessary
to examine the sputa systematically and thoroughly, both
morphologically and bacteriologically, and under certain
conditions even chemically, as frequently as possible, until
the diagnosis is assured. In Table I there are 143 instances
out of 374 in which no mention is made of the sputum. It
is, therefore, not ascertainable whether in these cases there
was any expectoration or what its character may have been
if present. In thirty-six cases it is clearly stated that there
was no expectoration. Stokes^ was the first to speak of a
pecuharly homogeneous and tenacious sputum, the color of
which he compared to black currant jelly and which is
spoken of by others as resembUng raspberry jelly or
prune juice. The latter designation is particularly used in
American textbooks. Stokes considered this sputum as
pathognomonic of lung tumor, especially of carcinoma,
and many textbooks still spread this behef. It has been
shown, however, that this peculiar sputum is per se not
pathognomonic for malignant tumors of the lung. It occurs
in other diseases, and even in primary carcinoma of the
lungs it is not constant and is recorded in but few cases.
Looking over Table I, it is foimd that the currant, rasp-
berry, and prune juice sputa have been placed on record
in only six out of the 374 cases. This may not absolutely
coincide with the actual facts, but it is reasonable to suppose
that where there is a clinical history given, so characteristic
a symptom would be mentioned. In Table II only two cases
are recorded out of a total of ninety. But though this kind
of sputum cannot be considered pathognomonic, it should,
in the writer's opinion, if associated with other symptoms
that all point toward tumor of the lung, be considered
corroborative of the diagnosis. The processes ultimately

^ Loc. cit.

CLINICAL 75

at work in the production of this peculiar type of sputum
are entirely unknown up to date. It seems certain that the
peculiar color is not merely due to the presence of blood;
there must be other conditions involved. Perhaps it is
not unreasonable to suspect that some specific kind of
haemolysis, caused, it may be, by some toxic product of the
tumor, formed only under certain conditions (perhaps oleic
acid — conf. Faust 0 is responsible. The subject has been
insufficiently studied and is well worth further research.

Bloody expectoration is associated with most cases of lung
tumors at some period of their development. The sputum,
either mucoid or mucopurulent, as the case may be, may
be intimately mixed with the blood, or the latter may
appear in the form of haemoptysis, varying in profuseness.
It has been claimed ^ that haemoptysis is uncommon in lung
tumors. According to the writer's own experience and
his study of the hterature of the subject, which is to a great
measure collected in the Tables, this statement cannot be
verified. It seems, on the contrary, that haemoptysis is of
rather frequent occurrence. A number of cases are reported
in which the very first symptom was a profuse haemoptysis,
others where haemoptysis occurred frequently in the course
of the sickness, and in quite a number of cases, sev-
eral of them under the writer's own observation, death
was caused by very profuse haemorrhage. The mere
bloody sputum, too, may appear as one of the very
first symptoms, though it sometimes requires all the skill
of a trained cross-examiner to elicit the fact that there has
at one time been some slight bloody expectoration. On
the other hand, blood may appear at a later stage, or even
at the very last stage, and sometimes, again, be constantly
present throughout the course of the disease. The records
in Table I show about one hundred cases in which the
sputum was bloody, not counting the currant, raspberry,
and prune juice sputa mentioned before, and not counting

^ 'Ober chronische Olsaurevergiftung, Archiv. f . exp. Path, und Phar.
Festschrift f. Schmiedeberg, p. 171.

2 West, Table I, No. 326. Also Hampeln, €ber den Auswurf bei Lungen-
carcinom, Z'tschrift f. klin. Med., Vol. 32, 1897, p. 246.

76 PRIMARY MALIGNANT GROWTHS OF THE LUNG

sixteen cases of profuse haemoptysis. In sixty-five of these
one hundred cases pure blood seems to have been expecto-
rated, representing, as it were, small hsemoptyses. The
others were various kinds of sputa, — mucoid, mucopuru-
lent, purely purulent, etc., — all of them mixed more or
less with blood. In three cases tubercle bacilli were found
in the bloody expectoration. In thirteen cases the sputa
were entirely free from blood. In forty-five cases the
expectoration was ordinarily without blood, and character-
istic merely of the condition of the bronchi and the lungs,
without reference to tumor. Greenish expectoration is
mentioned twice, and one case is reported of olive-green
sputum.^ Just what kind of sputa these are cannot be
ascertained, as there was no detailed examination recorded.
They are probably not characteristic. In Table II sputum
is not mentioned in thirty-one cases, in eight cases no
expectoration took place, in ten others there was not even
a cough, while twenty-five were bloody, three with profuse
hsemoptyses. In twelve cases haemoptysis is the main charac-
teristic of the sputum. Green sputum is noted five times,
and it is believed that Bell ^ was the first to mention it as
occurring in sarcoma. There are no means of judging of
its character or its relation to sarcoma. In Janssen's case^
the sputum was not merely green, but grass-green, and he
believes this to be characteristic of sarcoma of the lung.
Traube ^ finds grass-green sputa associated with pneumonia
or bronchitis, accompanied by jaundice, — the so-called
''bilious pneumonia," — and also in chronic pneumonia
without icterus. He claims that the varying colors of these
sputa are due to the red blood cells and the hsematin going
through the same cycle of discolorations as an ordinary
haemorrhage into the skin, the last being green and repre-
senting, according to Traube, the last stages of oxidation of
the haematin. He does not mention tumor.
That grass-green sputum cannot be characteristic of sar-

1 Elliott, Table III, No. 24.

» Table II, No. 3.

3 Table II, No. 39.

* Gesammelte Beitrage f. Path. u. Phys., Vol. II, 1871, p. 699.

CLINICAL 77

coma of the lungs may be deduced from the fact that it does
not appear in the majority of cases, while sputum, mentioned
as merely green, is seen in carcinoma, as well as in other
diseases of the lungs and bronchi. Moreover, grass-green
sputum is said to occur rather frequently in cases of chronic
pneumonia and of pulmonary abscess. Here, also, further
study is imperative, not only to determine the diagnostic
value, but also the conditions under which such peculiar
sputa are produced. Perhaps there is some special conjunc-
tion of circumstances in cases of sarcoma of the lung which,
while not occurring very frequently, produces when present
this peculiarly characteristic sputum. The writer feels that
in a case of suspected sarcoma of the lungs the grass-green
sputiun of Janssen would be strong corroborative evidence.
It seems at first glance almost self-evident that sputa from
a malignant growth of lungs and bronchi must necessarily
contain tumor elements, and that thus the diagnosis of such
tumors could easily be made certain beyond doubt. Some
reflection will show, however, that this is not so simple as it
seems, and must in fact be a rather rare occurrence. There
are first to be considered the quantities of various kinds of
epithelial cells that can normally be present in the mouth
and air-passages; the cylindrical cells, ciliated and without
cilia, that come from the bronchi, the nose, etc., the possible
admixture of cells from the oesophagus, etc., all of which
would prevent the direct recognition of tumor cells. It is,
therefore, always hazardous to suspect lung tumor merely
from the presence of scattered epithelial or round cells. On
the other hand, if the cells in question occur in unusually
large quantities and more or less constantly, or if cells which
normally are not found in the expectoration are constantly
present, the suspicion of tumor is permissible, provided the
clinical symptoms correspond. The tumor elements are
not apt to be expectorated unless there is open communica-
tion with a bronchus and the tumor itself has softened and
is in a state of incipient disintegration. Tumor cells, also,
that are expectorated under such circumstances are as a
rule in such a state of degeneration that their character as

78 PRIMARY MALIGNANT GROWTHS OF THE LUNG

derivatives of a neoplasm can only be recognized if some
remnants of their blastomic structm-e and organization
remain. This, of com"se, would make the diagnosis abso-
lutely certain, especially as secondary lung tumors seldom
cause marked symptoms, and never such as are peculiar to
primary growths. Some cases in point are on record. It
has even happened that a portion of necrosed lung tissue has
been expectorated before any other symptoms of pulmonary
disease were apparent, as in the case of Claisse.^ In the
case of Ehrich,2 villous and bloody masses containing can-
cerous material were expectorated. Pearson^ records a case
in which pieces of necrosed lung tissue were coughed up,
accompanied by tubercle bacilli, and the tumor was diagnos-
ticated by him as ''encephaloid." A similar case was that
of Turnbull and Worthington,^ in which a lump the size of
a walnut, of alveolar structure and containing cylindrical and
cuboidal ceUs, was expectorated. Still another, was the case
recorded by Peacock,^ in which masses were expectorated
consisting of spindle and round cells. There are a number of
other cases which can be found by reference to the Tables,
most of which are doubtful, however, because they lack the
all-important microscopic examination. Most of the cases
in which the expectoration is recorded of larger or smaller
portions of tumor, which are degenerated but nevertheless
distinctly recognizable as either carcinoma or sarcoma,
belong as a rule to late stages, and while they clinch the
diagnosis they do so at a time when all hope of beneficial
therapeutic interference is practically gone. It is quite
natural therefore that anxious search is made for elements
whose appearance in the sputum, while characteristic of lung
tumors, is not delayed until the later stages of development.
Hampeln ^ found certain cells in the expectoration from cases
of carcinoma of the lungs which, according to him, if only

^ Table I, No. 52. In the discussion of this case, Troisier reports a case of
primary cancer of the lung in which the diagnosis was confirmed by tumor
particles in the sputum. Menetrier also reports similar cases.

2 Table I, No. 78. ^ Table III, No. 59.

3 Table I, No. 249. e Loc. cit.
« Table I, No. 321.

CLINICAL 79

seen but a single time, assure the diagnosis of carcinoma.
He says, '^ Polymorphic, polygonal cells that are entirely
free from pigmentation are seen in the sputum where there is
carcinoma of the lungs, and in no other case but carcinoma.
In all other cases, if there are epithelial cells at all in the
sputa, they are principally round or oval cells, pavement or
ciliated cells, highly pigmented." These cells do not seem
to have gained favor in the eyes of diagnosticians. The
writer is not aware that Hampeln's views have been corrob-
orated by others, and he himseK has never seen the cells in
question. He must confess, however, that his examinations
with reference to them have not been sufficient to warrant
a definite conclusion. Lenhartz^ finds large spherical cells
filled with a multitude of fatty granules and associated with
abundance of epithelial cells that are strangely deformed
and possess club-like or tail-like projections. He is of opinion
that these fatty or granular cells are pathognomonic of pul-
monary carcinoma. Tuberculosis may be present without
changing anything in the character and diagnostic value of
these cells. In Table I the granular fatty cells are found in
the sputum seven times. The writer is inclined to agree
with Lenhartz that these cells are strictly pathognomonic,
at least of carcinoma of the lung, there being as yet insuf-
ficient experience as to sarcoma. Since the writer's attention
was drawn to these cells he has found them in every case
of primary carcinoma that has come under his observation
(about twelve cases), and a very long and close study of sputa
from all manner of other lung diseases tends to show that
they occur in carcinoma alone. The technique of examina-
tion is very simple, inasmuch as no staining is required,
and a spread of sputum, not too thin, perhaps in a little
glycerine and water, or perhaps without any addition, if
examined carefully with a moderate magnification, will not
fail to show these ''Kornchenzellen" if they are present.
The cells can sometimes be obtained, also, by puncture of
the pleura or the tumor. 2 It is to be remembered that the

1 Miinch. Med. Woch., 1898, No. 1, p. 28.

2 Muser, Table I, No. 209.

80 PRIMARY MALIGNANT GROWTHS OF THE LUNG

conditions under which these cells are formed are still un-
known. Lenhartz believes that they are produced by fatty
degeneration of the large epithelial cells of the tumor. This,
however, is merely hypothesis. Their appearance in the
sputum, — for what reason is not known, — is, moreover,
very inconstant and irregular. It may be necessary to hunt
for them for days in succession before they are found; it may
be, on the other hand, that the first examination will show
them. They may occur in great profusion, or again only
scattered singly here and there through the smear. But it
is the writer's conviction that when found they are pathog-
nomonic of pulmonary carcinoma, and furthermore that a
daily, systematic examination of the sputum is necessary
and that one should not be discouraged if the cells are not
found at once.

IV. That respiratory difficulties constitute one of
the most frequent symptoms in lung tumors is obvious. An
insignificant shortness of breath on slight exertion is fre-
quently reported as the first symptom. This may be present
long before percussion and auscultation give evidence of
any lesion in the lungs. The difficulty in breathing is
often so slight that only a rigid inquiry will elicit the fact of
its existence. Its gradual increase may be the first thing
to alarm the patient and cause him to submit to a medi-
cal examination. Beginning with this slightest form of
dyspnoea, all transitions up to the severest orthopncea occur.
Among the material here collected, numerous examples
will be found of death from suffocation. No physician
who has ever seen the intolerable and hopeless suffering of
those unfortunates who are doomed to the awful death by
suffocation accompanied by intensest orthopnoea extending
over weeks, sometimes even months, will ever forget it.
Fortunately, it is not always continuous, but is apt to come
in spells. Nevertheless, it is one of the most cruel tortures
to which man can be subjected and before which the physi-
cian has stood powerless. Not only is he unable to cure,
but even to relieve, as morphine loses its virtue and surgery
is helpless. Complete closure of a bronchus does not cause

CLINICAL 81

these worst forms of suffocation, but at most only a very
moderate degree of dyspnoea following exertion. The in-
tensest forms are brought about mainly by compression or
obstruction of the trachea. The tumor may grow up from
below through a main bronchus into the trachea and thus
obstruct it, or, as is perhaps more frequently the case, in-
volvement of the mediastinal glands may form large masses
pressing upon the trachea from without so as to produce
almost entire closure. Though a most frequent symptom,
dyspnoea does not necessarily complicate lung tumors. In
Table I there is a record of twenty cases in which no dyspnoea
of any kind was found throughout the disease. There are
189 cases where dyspnoea is not mentioned. In 165 instances
dyspnoea was present, and this number includes all the differ-
ent forms of respiratory disturbance, from the slightest incip-
ient dyspnoea to the most terrific orthopnoea. In Table II
appear two cases in which it is recorded that no dyspnoea
was present, fifty-two cases in which dyspnoea is recorded
as present at some stage of the disease, leaving thirty-six
cases in which no mention is made of this symptom.

V. Cachexia, the usual companion of malignancy, is
also a very frequent accompaniment of lung tumors. Its
incidence, however, is extremely irregular. There are cases
on record, as the Tables show, in which loss of flesh and
weight are apparently among the earliest symptoms, cer-
tainly before anything abnormal could be detected on the
lungs. ^ In other cases there is no apparent loss in flesh and
weight throughout the course of the disease. In one of the
writer's own cases,^ though there were profuse haemorrhages
and the disease lasted about four years, the man kept stout
and florid and apparently without any loss of strength until
his death, which was caused by suffocation from a profuse
and sudden haemorrhage. A positive gain in weight during
the progress of the disease has been observed by v. Fetzer'

1 Rottman, Table I, No. 277.

2 Table I, No. 3.

' Bronchuscarcinom, Correspondenzblatt Wiirtemberg artzlicher Landes-
verein, Feb. 25, 1905.
7

82 PRIMARY MALIGNANT GROWTHS OF THE LUNG

and also by Rothman.^ Le Sourd ^ reports a distinct ten-
dency to obesity throughout the disease. Notwithstanding
all that, a great number of cases are recorded in which death
ensued from exhaustion.

VI. There is still considerable diversity of opinion as to
fever in carcinoma and sarcoma of the lungs. Kast^ and
Ebstein and others recognize a somewhat typical intermit-
tent, but usually not very high, fever in the course of the
growth of sarcoma. DaroUes ^ is of opinion that there is no
fever in uncomplicated cases of carcinoma of the lungs. On
the other hand Hampeln ^ finds an intermittent fever similar
to the malarial type in cases of occult visceral carcinoma.
The same is maintained by Kast^ and a number of others,
who also find fever of an intermittent character, especially
in cases of cancer of the stomach. Without going into the
details of this subject for carcinoma in general, but consid-
ering only the carcinoma of the lungs, it appears, looking over
the list of cases, that such as seem to be uncomplicated have,
as a rule, no rise of temperature of any significance. That
fever in an absolutely uncomplicated case of cancer of the
lungs is possible, cannot be denied, in view of the modern
researches on auto-intoxications and metabolic disturbances
caused by the carcinoma itself. In the case of cancer of the
lungs, however, it is hardly possible to determine whether
the tumor is uncomplicated or not, and in the overwhelming
majority of cases it will probably be sufficiently complicated
by bronchitis, inflammatory conditions of the lung tissue,
bronchiectatic dilatations, etc., to account for whatever
temperatures may occur.

VII. Difference in pulse in the two radials has fre-
quently been reported. This is easily explained by the tumor
pressing upon one or the other of the subclavian arteries.

1 Table I, No. 275.
» Table I, No. 179.
' Jahrbuch der Hamburger Staatsanstalten, 1889, I.

* Du cancer pleuro-pulmonaire au point de vue clinique. These, Paris, 1877.
»Z't8chrift f. klin. Med., 1884, Vol. 8, p. 221; and 1888, Vol. 14, p. 566,

Zur Symptomatologie okkulter visceraler Karzinome.

• Loc. cit.

CLINICAL 83

Japha^ reports a distinct bradycardia in one of his cases,
but no cause for it is mentioned. So far as one can see
from the clinical and post-mortem notes, it does not seem
to have any connection with the lung tumor.

VIII. The blood count has not thus far been of much
assistance in the diagnosis of lung tumors. There are but
a few cases in which the blood count is reported, — in all
less than a dozen, — and even these lose greatly in value
inasmuch as it does not appear from the records how the
haemoglobin was estimated and how often and under what
varying conditions the blood count was done. One almost
involuntarily gets the impression that the blood count was
done only once, while it is obvious that it should be repeated
at stated intervals. Here also is a fruitful field for further
investigation.

Of the few blood counts that are on record, it may
be well to mention, first, that of Kappis.^ He finds
cancer cells with mitosis in the sputum. The blood he
reports as follows: Hb., 120; red cells, 6,200,000; white
cells, 50,560-40,700; eosinophiles, 33-39^-12%; polynu-
clears, 56.9%. The pleuritic effusion was a sanguinolent
serum which contained no eosinophiles. In this case the
blood count appears to have been taken repeatedly, but is
thus far inexplicable in that there is nothing in the history
as given by the author to explain the enormous leucocytosis,
the accompanying polycythsemia, and the very high per-
centage of eosinophiles, the polynuclears, at the same time,
being rather low. The autopsy also throws no light upon
this curious condition. The author remarks in his descrip-
tion of the microscopical structure that enormous heaps of
eosinophiles were found in places free from tumor. It is
best in this case to indulge in no hypotheses as to the possible
cause of this blood picture and its contradictions.

Another imperfect blood count is given by Naun^: Hb., 40;
leucocytes, 15,000. It is to be regretted that the number
of erythrocytes is not stated, because without knowing the
number of red cells one is left in doubt whether this is a

1 Table I, No. 136. » Table I, No. 139. ' Table I, No. 224.

84 PRIMARY MALIGNANT GROWTHS OF THE LUNG

mere haemoglobin anaemia with a moderate leucocytosis,
or whether the red cells also are diminished. A complete
blood count, including differential, and repeated several
times during the course of the disease, should in the future
be considered an essential requirement. In a similar way
Musser^ records merely increased leucocytosis, without fur-
ther details, in both his cases. In two of the writer's own
cases, 2 where the advantages of hospital observation could be
had, the blood count was taken repeatedly with the average,
in Case No. 2, of: Hb., 65; red cells, 4,500,000; leuco-
cytes, 15,000. This corresponds very nearly with the blood
count given by Cohen and Kirkbride^: Hb., 60; red cells,
4,400,000; leucocytes, 18,000; differential count of leucocytes
not stated. In Case No. 4 the blood count was as follows:
Hb., 62; red cells, 3,980,000; leucocytes, 14,300; differen-
tial fairly normal. In this case, besides the haemoglobin
anaemia, there is a distinct reduction in the number of red
cells, but no deformation or other alterations in them.

The case of Ebstein^ is very similar to this latter case:
Hb., 62; red cells, 3,492,000; but the leucocytes are unusu-
ally high, there being 32,000 (differential not stated). It is
impossible at present, there being so few blood counts avail-
able, to come to any definite conclusion. The leucocytosis
is easily accounted for by the inflaromatory and often puru-
lent processes going on in the lungs. Whether there is a
real disproportion between the number of red cells and the
percentage of haemoglobin, thus pointing perhaps to some
haemolytic process, or whether in the majority of cases there
is only the usual anaemia, both of red cells and of haemo-
globin, to be expected in any case of increasing malignancy,
— especially if there is considerable loss of blood, — is a
problem that awaits further study. In the case of Cohen
and Kirkbride the disproportion between 4,400,000 red cells
and only sixty haemoglobin is very striking. The blood
counts given by Faust ^ show some resemblance to the

1 Table I, Nos. 222 and 223. * Table I, No. 76.

2 Table I, Nos. 2 and 4. ^ Loc. cit.

3 Table II, No. 13.

CLINICAL 85

blood counts mentioned here, inasmuch as his rabbits
showed a continuous decrease in the haemoglobin with a
comparative increase in the red cells and a tendency to
some leucocytosis. The interesting coincidence is certainly
worthy of note.

Miiller^ has among his cases no case of lung tumor.
As a result of his careful blood counts nothing character-
istic is shown. The haemoglobin has a tendency to go
down steadily, as also the number of red cells, and there
is a tendency to leucocytosis and to an increase of the
polynuclear cells, but nothing characteristic of the blood
in lung tumors is shown.

IX. Incidentally, there should be mentioned two cases in
which diabetes was a complication of the disease, as in the
cases of Kratz^ and Liibbe.^ There is no evidence, so far
as can be seen, that the diabetes stands in any relation to
the lung tumor.

X. The clubbed fingers which are sometimes reported
have, it is obvious, no specific relation to malignant growths.
They are not different from the clubbed fingers that we see
in other chronic diseases, especially of the lungs, and more
particularly where pus is present.

1 Oswald Miiller, tjber den Blutbefund bei Krebskranken, Diss. Berlin,
1909.

2 Table I, No. 151. » Table I, No. 187.

CHAPTER IX

CLINICAL {.Continued)

WHEN one is compelled to face the almost infinite
variety of pathological lesions and compUcations
that are associated with most of the primary malignant
neoplasms of the Imigs, the clinical pictm^es and their
symptomatology appear to present an almost hopeless con-
fusion. A larger experience and comparative study will
show that there is, after all, a certain monotony of essen-
tial sjTuptoms, around which the varying complications and
lesions are grouped. It is possible in this way to arrange
the entire clinical material at our disposal into certain groups
which, with their subdivisions, supply a fairly well-classified
arrangement of the clinical phenomena. A certain number
of tumors, as has been shown above, are apt to withdraw
themselves from diagnosis by causing no symptoms whatso-
ever, and others in which a diagnosis is not likely because
symptoms caused by metastatic deposits^ completely domi-
nate the chnical picture and successfully mask the pulmonary
disease. For the great majority of tumors which do produce
symptoms, the remark of Stokes, that ''the faciUty of
diagnosis mainly depends on the anatomical disposition of
the disease," is still true.

According to Passler,^ the clinical pictures accom-
panying pulmonary mahgnant neoplasms can be aptly
arranged in two main groups. The first group contains

1 There is much difference of opinion among authors as to the frequency of
metastases in maUgnant tumors of the lung, some claiming that secondary
deposits are very rare in carcinoma and correspondingly numerous in sarcoma,
others expressing directly opposite opinions. By consulting Appendices C
and D the reader will obtain a fair idea of the occurrence of metastases in the
various organs both in carcinoma and in sarcoma and he will find very little
difference between carcinoma and sarcoma in this respect.

2 Loc. cit.

CLINICAL (Continued) 87

the cases in which the symptoms referable to diseases of
the lungs and bronchi largely predominate. These tumors,
mostly carcinoma, nearly always take their origin from the
bronchial ramifications from the second order downwards
to the smaller and smallest bronchioles, and as a rule do
not directly implicate the hilus. The second group
embraces to a large extent the tumors of the root of the
lung. This group may be accompanied by intense and
agonizing symptoms on the part of the respiratory organs:
lungs, bronchi, etc.; but these are usually of a secondary
nature, though they may dominate the clinical picture.
The typical symptoms of this variety of lung tumor are
largely mechanical and composed mainly of such symp-
toms as result from pressure on or compression of the tho-
racic organs, especially of the mediastinum, and from the
overcrowding of the intrathoracic spaces. The elementary
symptoms mentioned above are common to both groups.

The classification of Marfan,^ identical in principle with
that of Passler, is perhaps a little more convenient, and is
adopted here. It reads as follows:

I. The acute or galloping form of pleuro-pulmonic cancer.
II. Chronic pleuro-pulmonic cancer.

1. Broncho-pulmonary type, being the classical type of carcinoma

of the lungs.

2. Type suggesting tiunor of the mediastinum.

3. Pleuritic type.

(a) Pleuritic type of the pleuro-pulmonary tumor without
effusion.

The first main division, the acute or galloping miliary car-
cinoma of the lungs, runs an extremely rapid course, accom-
panied by cough, dyspnoea, and asphyxia; death usually
in a month or thereabouts. The clinical picture in many
respects resembles that of acute miliary tuberculosis, and at
autopsy both lungs and pleura are found studded with
miliary nodules which, however, on microscopic examination,
are found to be cancerous. This form is extremely rare and
only a very few scattered cases have been reported. The
case of Elisberg2 may possibly come under this heading. In

* Quoted from Chauvain, loc. cit. * Table I, No. 80.

88 PRIMARY MALIGNANT GROWTHS OF THE LUNG

this case the primary tumor was in the bronchus. It is
generally denied that this form of carcinosis ever occurs
as a primary pulmonary lesion. This statement, however,
cannot be supported by absolute proof. Granted that it
does occur as a primary lesion, it seems that at present there
are no means of obtaining a correct diagnosis during hfe.

II. The chronic pletjro-pulmonary cancer. This is
the ordinary chronic form of cancer of the lung, in which
the lungs, bronchi, and pleura are mainly affected by the
tumor. The subdivisions which have been mentioned are,
it is necessary to insist, merely for the convenience of the
clinician and do not represent strictly defined and firmly
established independent syndromes. With the progressive
development and extension of the blastomic lesion, accom-
panied by a varying degree of destruction of the lung and
the secondary effects of the tumor on its environment, the
symptoms must necessarily vary, and the so-called subor-
dinate groups may merge one into the other. It may
often be observed that several or all of the various types
here mentioned are exemplified in the course of a single
case.

1. Pulmonary cancer. The classical type of cancer
of the lung. This represents the ordinary bronchial carci-
noma which, as shown above, is by far the most frequent
form of the disease. The dominant symptoms are referable
mainly to the lungs and bronchi. The earlier stages usually
suggest merely a chronic bronchitis.

It is commonly said that in the very earliest stages of the
development of the tumor, percussion will fail to show any
appreciable difference from the normal. This may, in the
main, be true. It is, however, the writer's deep conviction
that, even in very early stages, percussion may be found
significantly altered, if a sufficiently dehcate technique be
adopted.

It cannot fall within the scope of this study to enter in
detail into a discussion as to the relative values of the vari-
ous methods of percussion or into the manifold theories
that have been put forward in this most important chap-

CLINICAL (Continued) 89

ter of diagnostics. But it is the writer's opinion that
the ordinary loud, resounding, finger to finger or hammer
to finger or plessimetre percussion cannot be made to
give proper results in these earher stages. The writer has
employed for years the " Schwellenwerthperkussion " and
orthopercussion as elaborated by Goldscheider, Plesch,
and Curschmann, in combination with the auscultatory
percussion according to Ewald and the friction method of
Bianchi. The results, checked by the orthodiascope, have
as a rule been most satisfactory. These methods, if carried
out with the dehcacy of touch and hearing which they
require, may be expected to lead to the detection of compara-
tively slight pathologic lesions where other methods of per-
cussion will fail. It is understood that percussion must vary
according to the different stages of development and the
various complications that may occur in the course of
malignant disease of the lungs.

There are cases on record, as for instance that of
Rottman/ where it is reported that physical signs on the
lungs were negative, although a large tumor was found.
This is only one of many similar examples reported. In
early stages a dull percussion note is found at one apex or
the other, or, which is much more difficult to find, at the
hilus posteriorly. The anterior aspect of the upper chest
is more frequently the seat of dulness than the posterior,
but the dulness at the hilus, of course, can only be heard
near the spine. This dulness may gradually increase from
a shght change in the percussion note to absolute flat-
ness. The flatness and boardlike resistance to the per-
cussing finger are very often due, not to the tumor itself,
but to the atelectasis caused by the tumor. Woillez 2 desig-
nated as characteristic of lung tumor what he called the
'Hympanisme thoracique," which consists of a tympanitic,
immediately preceding the full, percussion note. This has
not turned out to be a pathognomonic sign and is wellnigh
forgotten.

1 Table I, No. 277.

2 Dictionn. de Diagnost. m6d., Paris, 1870, 2d Ed.

90 PRIMARY MALIGNANT GROWTHS OF THE LUNG

Characteristic of these earher stages is, further, the
fact that with dull or flat percussion, auscultation shows
diminished respiration. Where pleuritic effusion or pleu-
ritic adhesions and thickenings can be excluded, which is
comparatively easy for the upper anterior portions of the
chest, this sign of increasing dulness with diminishing voice
and breathing sounds is extremely suggestive, and while
not absolutely pathognomonic of tiunor, should make the
presence of tumor highly probable. The mechanism of
the sign, — increasing dulness with diminishing voice and
breathing without pleuritic effusion, — is of course given in
the more or less complete obstruction of a bronchus, by
which means those portions of the lung not affected by
tumor are in a more or less complete state of atelectasis.
Most interesting in this connection is the case reported by
Korner.i In this case there was flattening of the right
chest, absolute flatness of percussion, and entire absence
of respiratory and vocal sounds, — in a word uncomphcated
and complete obstruction of the right main bronchus, a diag-
nosis that was confirmed by autopsy. The area of dull per-
cussion note in these cases is usually sharply defined, as
distinguished from tuberculosis and pneumonic conditions,
where the delimitation is more diffused, the abnormal per-
cussion merging gradually into the normal. The configura-
tion of the area of dulness or flatness is, however, usually
quite irregular, according to the topographical disposition
of the tumor, its depth, its extension, and its surrounding
reactive processes.

As the tumor grows and degenerations of various kinds
make their appearance, as breaking-down and irregular
excavations in the tumor come about, — and it has been
stated above that this happens much more frequently than
most authors concede, — the percussion note and ausculta-
tory signs must necessarily change in character and become
variable to a considerable extent. Tympanitic percussion
note, amphoric breathing, metallic rales will show the
presence of a cavity, and when a case has reached this stage

1 Table I, No. 147.

CLINICAL (Continued) 91

one is apt to pardon the clinician who does not hesitate to
diagnosticate tuberculosis. Besides more or less profuse
haemorrhages, it is not unusual to find at this stage irregular
fever of considerable intensity and night sweats. The fever
may resemble the hectic type. Notice is to be taken, also,
of the bronchiectatic dilatations which occur so often and to
so great an extent, as a consequence of obstructed bronchi.
Here percussion as well as auscultation offers frequently
interesting changes. If the bronchus is completely closed
for a long time, the bronchiectatic cavity naturally fills with
secretion, — pus, mucus, blood, and so on, — possibly
continually dilating, and the percussion note over this will
be dulness to flatness, and auscultation will hear neither
voice nor breathing. Suddenly, as it were, the bronchus is
reopened by ulceration and degeneration of the obstructing
tumor, there is a free discharge of the bronchiectatic con-
tents, and in the place where formerly there was abso-
lute flatness, we have now the tympanitic note and the
auscultatory symptoms pointing to a cavity.

It is obvious that these signs can only occiu" in very
late stages of the disease. The process may be varied
in different ways and it may be taken as characteristic
of these later ulcerative stages when such sudden changes
in auscultation and percussion appear. As a good illus-
tration of these conditions may be mentioned the case of
Amal.^ In this case there was total absence of breath-
ing, but normal percussion over the entire right lower
lobe. There were all the other symptoms of a malignant
growth in the lungs. Very suddenly, and only a few days
before death, the respiratory murmur was again distinctly
heard over the right lower lobe, — in other words, the tumor,
partly compressing, partly proliferating into the right main
bronchus of the lower lobe and completely filling it and
preventing the passage of air, had ulcerated away to a
great extent and thus again permitted communication with
the air. It has frequently been said that percussion over a
neoplasm of the lung offers a greater resistance to the finger

» Table I, No. 13.

92 PRIMARY MALIGNANT GROWTHS OF THE LUNG

than is normal. This sign, however, depends on so many
varying factors, as the closeness of the tumor to the chest
wall, the condition of the lungj etc., that it is not constant
and not characteristic, though when present a welcome
corroboration.

Another sign of great diagnostic value is the auscultatory
symptom, to which Behier ^ gave the name of ''cornage."
This is a sound very similar to that obtained from the
trachea when partially compressed. It is pathognomonic of
bronchial obstruction and might be considered, especially
when heard about the root of the lungs, and better still
when accompanied by some dulness, as an almost certain
sign of tumor. It must be remembered, however (and for
that reason the word ''almost" is inserted), that certain other
conditions which may result in bronchial obstruction must
be excluded. This should not be difficult, for probably all
the processes which may result in bronchial obstruction,
and thus in an audible cornage, are acute. Thus it is not
unusual to find the sign in acute, severe bronchitis or in an
influenza pneumonia, or even in chi'onic bronchitis when a
bronchus happens to be obstructed by masses of viscous and
tenacious mucus. But in all these cases the obstruction is
temporary and disappears as a rule in twenty-four hours.
But in tumor the cornage is practically constant and will
remain so until the bronchus is completely obstructed, or
will disappear after a comparatively long time when the
bronchus, through ulceration, becomes again freely perme-
able to air. Cornage may be a very early symptom.

2. The mediastinal type of lung tumor. A bronchial
cancer, — and it is indifferent of what order the bronchus
may be, whether large or small, — has two main preformed
routes of extension at its disposal. The easiest and most
natural, and the one that is in the majority of cases primarily
resorted to, is along the bronchial ramifications and the
peribronchial tissues into the interior of the lung. This
holds good also for those sarcomata that originate in the
minute peribronchial glands or in the peribronchial connec-
1 Gaz. de Hop., AprU, 1867.

CLINICAL (Continued) 93

tive tissue. In the later stages the bronchial wall is apt
to be broken down and penetrated by the tumor, and thus
the bronchial and then the mediastinal lymph nodes become
involved and are occasionally enormously enlarged. The
mediastinal lymph nodes, possibly both anterior and pos-
terior, now take part, the mediastinum is filled with tumor
masses, the pericardium may be covered or even penetrated
by the neoplasm, pericarditis develops, secondary growths
in the heart appear, the large vessels, both aorta and cavse,
the pulmonary arteries and veins are surrounded and either
compressed or penetrated by the tumor. It should be
mentioned that the aorta, while often much compressed,
so far as the writer's knowledge goes, never takes part in the
tumor proliferation and is never penetrated by it. As a con-
sequence of all this crowding of the mediastinal organs, the
superficial veins of the chest are dilated, sometimes to a huge
extent, and cedcema, varying from cedoema of a single arm,
or the face, to a general oedoema of the entire body, arises.
One or the other, sometimes both, of the laryngeal recurrent
nerves are involved, the trachea, large bronchi, oesophagus,
are compressed, obstructed, and even penetrated by the
tumor. The participation of the oesophagus causes the
dysphagia so frequently reported. And thus all the symp-
toms of an intrathoracic growth, or more especially of
primary mediastinal tumor, are evolved. Sarcoma, origi-
nating at the hilus of either lung, differs from this group of
symptoms in so far as the direction of the growth is less
towards the lung and tends to advance more rapidly and
at an earlier stage of the disease toward the mediastinum.
It is this mediastinal type of tumor that usually causes
the dreadful attacks of asphyxia and orthopnoea mentioned
above.

3. The pleuritic type. In cases belonging to this type,
the symptoms referable to the pleura predominate. So far
as tumors of the lungs and bronchi are concerned, this
form corresponds to a rather late stage of the disease. In
primary mahgnant disease of the pleura, however, which is
beyond the scope of this monograph, this form usually marks

94 PRIIMARY MALIGNANT GROWTHS OF THE LUNG

the beginning of the lesion. The symptoms in the main
are those of acute, sub-acute, or chronic pleurisy. There
is stabbing pain in the chest, radiating to the shoulders or
in other directions, and all the signs of a persistent pleuritic
effusion, which too often tend to mask more or less com-
pletely the symptoms of pulmonary disease. We have the
absolute flatness on percussion, the total absence of voice
and breathing on auscultation, very often the obliteration of
the intercostal spaces, frequently the bulging of these same
spaces.

In nearly every case of lung tumor, the pleura partici-
pates to a certain extent in the morbid process, sometimes
with sometimes without effusion; according to Herrmann ^
in fifty per cent of the cases. In this pleuritic type, how-
ever, effusion more or less profuse is always present and is
hkely to recur after tapping of the chest, so that these
tappings must be repeated again and again, at longer or
shorter intervals. In ordinary pleurisy the aspiration of the
effusion affords prompt reUef of the harassing symptoms.
Even in the pleurisy associated with extensive tuberculosis,
this rehef can be recognized. It is characteristic of the
type of tumor under discussion here, — though it applies
also to primary carcinoma of the pleura, — that relief after
removal of the pleuritic effusion either does not follow at
all, or lasts but a very short time. As a rule there is
no abatement of the cough, dyspnoea, expectoration, and
general distress, but there may be intense pain caused by
the wrenching of the diseased tissues. Some exceptions to
this fairly general rule are on record, such as the case of
Unverricht,2 where, after one or two aspirations of sanguin-
olent fluid, all symptoms seemed to disappear, the patient
felt entirely well and gained in weight, until secondary
tumors made their appearance in the skin where the aspirat-
ing needle had penetrated. Hampeln^ also reports a case

1 Deut. Archiv. f . klin. Med., Vol. 63, 1899, p. 583.

^ Beitrage zur klin. Geschichte der krebsigen Pleuraerglisse, Z'tschrift f. klin.
Med., Vol. IV, 1882, pp. 79 ff.
3 Table I, No. 101.

CLINICAL (Continued) 95

in which the pleuritic effusion was absorbed without tapping
and without recurrence. These cases, however, are rare
exceptions.

The fluid recovered by the first few tappings may be
clear yellow serum, but sooner or later it is certain to
become bloody. It is well known that bloody pleural
effusion occurs in other diseases, especially in tuberculosis,
and is in itself, therefore, not pathognomonic of malignant
tumor of the lungs or pleura. It is said, however, that the
change from initial clear serum to bloody effusion is charac-
teristic of neoplasms of the lung. It is uncertain whether
this is correct or not. It is reported, on the other hand,
very often that a thick, chocolate-hke fluid is recovered in
the later tappings. This, according to the writer's opinion,
is certainly pathognomonic for malignant disease in the
pleural cavities. Adipose and chylous effusions into the
pleura are reported, but are found very rarely in malignant
neoplasm of the lung, — certainly much less frequently than
in the disease of the peritoneum. The same holds good
for empyema. In the case of Walch^ it was evidently a
pneumococcic affection and had no direct relation with the
carcinoma. Nothing characteristic has as yet been found
by the bacteriological examination of the pleuritic effusions.

The results of the cytological examinations have been a
subject of much discussion, with no positive conclusions.
Ehrhch^ has called attention to the diagnostic importance
of the presence of organically connected cell-groups in the
effusion. Frankel has called attention to large vacuolized
cells, sometimes attaining gigantic dimensions. These are
probably tumor elements and this is assured if they are
found to contain glycogen, but they probably belong to
primary diseases of the pleura. It is therefore not very
difficult to diagnose the presence of malignant tumor in the
chest from the study of the cells in the effusion, if such can be
found. It is, however, almost impossible, under the condi-

* Cancer du poumon gauche, pleur^sie purulente pneumocoques, Soc. anat.
de Paris, 1893, VII, Ser. 5.

» P. Ehrlich, Charit6-Annaleii, 1880, Jahrg. VII, p. 226.

96 PRIMARY MALIGNANT GROWTHS OF THE LUNG

tions given, to distinguish an endothelial from an epithelial
cell, and therefore a primary endothelioma of the plem*a from
a carcinoma of the Imigs, and it is wise not to depend for
diagnosis on the cytology of the pleural exudate alone.
This rule should hold, even though exceptions are possible,
as in the case of HeUendall,^ who found in the bloody effu-
sion in the chest white particles consisting of heaps of round
cells, sufi&ciently characteristic to warrant the diagnosis of
sarcoma of the lung, — a diagnosis which was confirmed
by autopsy. Kronig,^ on making a probatory puncture,
penetrated the tumor with the needle and found attached
thereto white particles which microscopic examination
showed to be lympho-sarcoma, and he was thus enabled to
obtain an absolutely certain diagnosis during life. He
devised a method based on this, by which in every doubtful
case the attempt was to be made to remove particles of
tumor by aspiration. There are serious objections to this
method. It is not only very uncertain in its results, as the
needle does not always return with tumor particles, but
usually only with a little blood, but there is actual danger
of causing a haemorrhage.

It may be taken as a trustworthy sign of malignancy if
a paralysis of the recurrent laryngeal is observed on the
side of the pleuritic effusion. It has been stated above
that as a rule there is no relief after removing the effu-
sion in cancerous pleuritic effusions. It may also be said
that, after removal of the fluid, the various phenomena
of percussion and auscultation, which until then had been
masked, will appear in unmistakable distinctness, and
thus greatly assist in the diagnosis. The dislocated heart *
which, on removal of the pleuritic effusion, will make
no attempt to return to its normal place, — other symp-
toms being favorable, — suggests tumor. The retraction of
the affected side of the thorax, accompanied by increased
dulness and impaired or entirely abolished respiratory
motions, when caused by a thickening of the pleura, some-
times to an enormous degree, is not at all characteristic of
1 Table II, No. 35. 2 Table II, No. 42.

CLINICAL (Continued) 97

malignant growth in the lungs after the stage of effusion
is over, but is well known to occur in other forms of
pleurisy, especially in tuberculosis.

(a) The pleuritic type without effusion. This is most
typical and applies almost exclusively to those large mas-
sive sarcomata or lympho-sarcomata that are apt to fill the
greater part of the chest. It marks, of course, a late stage
of the disease. There are all the signs of a pleuritic effu-
sion, often increased circumference of the side of the chest
involved, displacement of the heart, etc. There may also
be present, but not necessarily so, the ordinary general
symptoms of maUgnant growth of the lung, — the cough,
dyspnoea, fever, sweats, haemoptysis, cachexia, etc. The
exploring needle fails to discover any fluid. On the con-
trary it seems to penetrate into a more or less solid mass
extending to such depths as to preclude any possibility
of its being merely an abnormally thickened pleura. Par-
ticles of tumor may be brought away by the needle. It
is characteristic of this type that, while there is complete
absence of respiratory murmur or vocal fremitus, there is
a very loud propagation of the heart sounds, so that if
the tumor occupies, for instance, the right chest, the heart
sounds can be heard very distinctly over the whole of the
right chest, both in front and in back.^ This sign alone is
sufficient to assure the diagnosis of a solid intrathoracic
mass. Consequently in most of these cases there is dilata-
tion of the superficial veins of the chest and possibly of those
of the abdomen, more or less intense dyspnoea, paralysis
of one or both recurrent laryngeal nerves, direct or indirect
affection of the heart itself, the large vessels, etc.

A few words should be said concerning some morbid
processes which are found in the train of pulmonary tumors.
Pneumonias, both acute and chronic, are among the most
frequent accompaniments of lung tumors. In a number of
cases the pneumonia is recorded as the first symptom. The
patients state that they were taken acutely ill with chill,
high fever, cough, rusty sputum, from which they recovered,

1 Withauer, Table I, No. 342. Budd, Table III, No. 13.
8

98 PRIMARY MALIGNANT GROWTHS OF THE LUNG

but that from then on they were never quite well. These
acute pneumonias may be pneumococcic pneumonias or pro-
duced by other well-known bacteria. The chronic form, if
not of the cheesy tubercular character, is principally of the
indurative type. These pneumonias may lead to symptoms
which mask the signs of the tumor, or at least are most
perplexing. Sometimes, though rarely, they are followed
by a genuine empyema. Atelectasis ^ has been mentioned
above and is the natural consequence of the blocking by
tumor of larger or smaller bronchi, resulting in the collapse
of the entire territory which the bronchus supphes with air,
as well as its splenification, if no change occurs in the
bronchus. There will be moderate dulness on percussion,
though sometimes, — particularly if the area is small, —
the percussion note will remain fairly normal. But vocal
fremitus and breathing sounds are completely abolished.
It is on account of these secondary processes that the
extent of the dull area does not coincide with the actual
size of the tumor. The tumor, as the X-rays have shown,^
may be larger than the dull percussion would lead one to
expect. On the other hand these secondary processes give
a dull percussion note of their own, which, merging into
that caused by the tumor, is apt to give an exaggerated
idea of the tumor's size.

Another complication which requires mention, though
abeady hinted at above, is gangrene. It is easily conceiv-
able, in fact it is almost self-evident, that a proliferating
tumor in the lung, rapidly destroying lung tissue and pene-
trating into blood vessels, can at any time envelop and, by
compression, obstruct an artery of some size, or, by breaking
through the arterial wall, close an artery completely, and
by either of these means cause total ischsemia, followed by
gangrene. According to the size of the artery involved,
the gangrenous territory will be larger or smaller, occasion-
ally occupying the greater part of a lobe. When a case is
first seen in this condition, the diagnosis is intensely diffi-
cult, — wellnigh impossible, — as even those signs in the

^ Korner, loc. cit. ' Leo, loc. cit.

CLINICAL (Continued) 99

sputum which we have found to be pathognomonic are apt
to be lacking. Under these conditions, too, the X-rays
will not give any useful information, and it is only by most
careful study of the history and the progress of the disease
that a probable diagnosis can be arrived at. On the other
hand, if the gangrene appears, after previous examination
and observation of the patient have settled the diagnosis
of tumor, or at least have caused tumor to be suspected,
the gangrene will rank only as a complication. It may be
casually added that there may be interesting involvements
of the sympathetic which will in no wise interfere with the
cardinal symptoms and the diagnosis, but which are of
interest as again demonstrating the manifold complications
that are constantly arising.^

It was not very long ago that A. Frankel ^ wrote that the
X-rays were of little service in the diagnosis of lung tumors.
Since then the X-rays have become a most remarkable and
efficient aid to diagnosis in general, and there exists the
well-founded hope of their increasing efficiency as further
improvements in the apparatus and advances in technique
are made. They have also proved, as is well known, a
powerful therapeutic agent in many diseases, but not as yet
for treatment of lung tumors. The hope may reasonably
be entertained that with the systematic and proper appli-
cation of the X-rays to the exploration of the chest, the
diagnosis of lung tumor may be assured when no other means
will give equally certain results. Leo^ diagnosticated an
osteosarcoma of the lungs, secondary to a sarcoma of the
right knee, during life, with certainty and much topograph-
ical detail by means of the X-rays, which also showed a much
greater extent of the tumor than could be ascertained by
percussion and auscultation. It may also be possible, per-
haps, to obtain this diagnosis at a time when the tumor is as
yet very small and causing but little subjective distiu-bance.

If this happy result is ever to be reahzed, it will be neces-

^ Kronig, loc. cit. ^ Loc. cit.

' Nachweis eines Osteosarkoms der Lunge durch Rontgenstrahlen, Berl.
Klin. Woch., Vol. XXXV, 1898, No. 16, p. 349.

100 PRIMARY MALIGNANT GROWTHS OF THE LUNG

sary to examine the chest with the Rontgen rays even where
there are no symptoms pointing to any disease in the chest.
It has been the writer's practice for a great many years, as
an essential part of the routine examination in every case that
presents itself at his office, no matter what the patient's
complaint, to subject the chest to a thorough exploration
with the Rontgen rays. We prefer the examination with the
orthodiascope (de la Campe) and a very large (12'''xl6")
fluorescent screen. Thus one is enabled at a single glance
to observe heart, lungs, in fact, taking advantage of various
positions, nearly all the thoracic contents during action. It
is particularly useful, also, for watching the respiratory
mobiUty of the lungs and diaphragm. It has repeatedly
been noted that in lung tumor the mobihty of the lung is
markedly diminished or entirely abolished. In cases of medi-
astinal tumor the respiratory mobility of the lung remains
unchanged or is increased, and Jacobson ^ has found this
valuable in distinguishing between the two types of tumor.
With good light, good apparatus, and some experience, com-
paratively minute lesions in the lungs can be discovered.
Any abnormality that is thus brought to notice can be per-
manently fixed for further reference by the photographic
plate, approximately accmrate measurements can be ob-
tained, and thus the gradual enlargement of the tumor
verified and its blastomic nature determined. The shadow
of a carcinoma or sarcoma just starting from the hilus and
gradually extending toward one of the pulmonary lobes is
a very striking picture when seen with the Rontgen rays,
and often suggests the tumor diagnosis when the observer,
though other characteristic symptoms were present, would
have been led astray. The interpretation is more difficult
when the shadow extends over the upper lobe of either side,
as this is the favorite localization of tuberculous processes.
Sometimes the sharp hnear delimitation at the base of
the shadow makes for tumor rather than tuberculosis. It
speaks for tumor, also, if the affection is confined to one

* Primare Lungen vmd Mediastinal Tumoren, Festschr. f. Lazarus, Berlin,
1889.

CLINICAL (Continued) 101

upper lobe, for as these pictures are seen only after the dis-
ease has progressed to a certain extent, the upper lobes of
both lungs, if the process were tuberculous, would probably
have been affected. The shadow remaining unilateral
speaks for tumor. The absence of tubercle bacilli in the
bloody sputum, with the increasing shadow on one lobe only,
also suggests tumor. But where tuberculosis is associated
with advancing carcinoma or sarcoma of the lung, the
Rontgen rays are of Uttle value, and if a differential diag-
nosis is possible, it must be attempted by other means.
It is beyond the scope of this study to enter into further
details concerning the X-rays. The reader is referred to
the well-known books of Holzknecht,^ Grodel,^ Grunmach,^
and Amsperger.* The details, however, as to the value of
the X-rays in malignant lung tumors may be studied by the
reader in the cases recorded by Otten ^ and Muser,^ from
the Eppendorf Krankenhaus, Hamburg, under the direction
of Lenhartz.

Another recent aid to diagnosis is the bronchoscope, that
has been so successfully employed in various affections of
the trachea and the larger bronchi. It has also done service
in establishing beyond doubt the presence of a bronchial
neoplasm. 7 Karrenstein^ reports the case of a male forty-
eight years of age, in which the tumor, taking origin from
the large bronchus immediately below the first division
of the right main bronchus, was made distinctly visi-
ble by the bronchoscope, the tumor having been suspected.
H. von Schrotter ^ reports a case of a male f orty-foiu-
years of age where the bronchoscope showed very plainly

^ Mitteil. aus Laboratorium fiir radiologische Diagnostik und Therapie,
Jena, 1907.

2 Rontgendiagnostik in der inn. Med., Miinch., 1909.

2 tiber die diagnostische und ther. Bedeutung der X-Strahlen f. d. inn.
Med. u. Chir., Deut. Med. Woch., 1899, No. 37.

* Die Rontgenuntersuchung der Brustorgane, Leipzig, 1909.

6 Table I, No. 228.

6 Table I, No. 205.

^ Killian, Zur diagnostischen Verwertung der oberen Bronchoskopie bei
Lungencarcinom, Berl. Klin. Wochenschr., 1900, p. 437.

8 Table I, No. 141.

« Table I, No. 325.

102 PRIMARY MALIGNANT GROWTHS OF THE LUNG

a prominent tumor in the right bronchus from which a
piece was exsected for microscopic examination, which
showed cancerous epitheUa with glycogen reaction, and
thereby settled the diagnosis.

It is always unwise to endeavor to prophesy as to future
possibilities, at least within the domain of biology and
pathology. It cannot be denied that the field of bron-
choscopy may be greatly extended by improvements in appa-
ratus and in technique. It is, however, the writer's opinion
that its usefulness in the diagnostics of lung tumor, at this
writing at least, is limited. It appears at present that from
the nature of things, bronchoscopy can make visible only
such tumors as have involved the upper bronchi. Of what
occurs in the bronchi of lower orders and in the depths of
the lung, the bronchoscope leaves us in utter ignorance.
Moreover, there are undoubtedly many cases that come
under observation, late in the course of the disease, where
the dyspnoea, brain involvements, and other concomitant
symptoms are of such gravity, and menace life to such a
degree, that even the boldest would hesitate to introduce a
bronchoscope, though there remained but little doubt that
the instrument could make visible the involvement of the
upper bronchi. In such cases the diagnosis should be made
by other means, — especially as even the exact recognition
of the tumor by the bronchoscope would be of little avail
to the patient.

In concluding the clinical part of the subject, it is still
necessary to mention a few points which may be helpful
in differentiating lung tumors from other diseases closely
resembling them in symptomatology, and for which they
might easily be mistaken. First and foremost, of course,
is the question — tuberculosis or tumor? This question can
be easily answered at autopsy, but it is not quite so simple
in the living person. Some points in the differential diag-
nosis have already been brought out. The small tumors,
particularly cancroids, described as growing from the
walls of a tuberculous cavity, will probably never be diag-
nosticated, unless pathognomonic cells in the sputum direct

CLINICAL (Continued) 103

attention to the possible existence of tumor in the respiratory
system. At any rate it is always advisable to remember
the exhortation of Gerhardt, — always to suspect tumor in
persons of advanced age where tuberculosis is not likely
and cannot be found by ordinary examination, and where
there is cough with bloody expectoration. It is plain
that the differential diagnosis as between tuberculosis and
tumor cannot be made at once, but requires prolonged and
most careful examination and observation. Even then it
will often be impossible to decide absolutely. That it can
be done, however, is shown, among others, by the follow-
ing case of Fessen.^ This concerned a man forty-five years
old, who had pulmonary phthisis and a cavity in the right
apex. Tubercle bacilli were found in the sputum. The
tuberculosis gradually improved and showed signs of
cicatrization. Opposed to this, however, was the cough with
scant expectoration, the general cachexia and sharply
defined complete flatness. The puncture was negative;
the Rontgen rays showed a dense shadow, very sharply
defined at its lower border. This alone sufficed to justify
a diagnosis of tumor of the lung. This diagnosis was
corroborated by the bulging of the intercostal spaces, the
dilatation of the veins, the small radial pulse on the affected
side of the chest, the oedcema, and all the symptoms of a
bronchial obstruction completing the clinical picture. The
autopsy showed a cicatrized tuberculosis of the left lung,
and in the right apex a cavity, and the lower portion of the
right upper lobe cancerous. ^ The sudden changes in percus-
sion and auscultation, of which mention has been made, are
not likely to occur in tuberculosis, but speak for tumor. The
absence of bacilli in the sputum, it is hardly necessary to
mention, may persist for a long time in tuberculosis, but in
advanced cases, especially where extensive ulceration has
taken place, tubercle bacilli are sure to make their appear-
ance. The modern tests for tuberculosis, — the injection
test, the Wolff-Eisner and von Pirquet tests, — will only be
helpful if persistently negative, as only in that case do they

1 Centralbl. f. innere Med., 1906, No. 1. « Wolff, loc. cit., p. 817.

104 PRIMARY MALIGNANT GROWTHS OF THE LUNG

help to exclude the presence of active tuberculosis. Further
experience and improvement in methods may possibly
result in greater facility and precision of this diagnosis.
Enough has been said to show that no hard-and-fast rules
can be given to diagnosticate lung tumor in a tuberculous
individual. The hints as to differential diagnosis that have
been given may serve in a general way as guides, but the
physician must mainly depend upon his own insight and
judgment in each individual case.

If a lung tumor happens to be first seen when it is far
advanced, the suspicion of the presence of an aneurysm
may arise. This is hardly to be expected in the ordinary
case of carcinoma of the lungs, where the history, the train
of symptoms as outlined, the cells in the sputum, etc., will
speak against aneurysm, although as a matter of fact an
aortic aneurysm is rarely to be absolutely excluded. The
differentiation as between sarcoma and aneurysm is some-
what more difficult, as sarcoma naturally tends to grow more
towards the mediastinum and away from the lungs than
does carcinoma. In some cases the Rontgen rays may help,
although as a rule they are useless. A tumor lying upon
or adherent to the aorta will pulsate. The pulsation is
generally of a lesser extent and more definitely circumscribed
in aneurysm, while in the case of tumor it is of a more
diffused character, involving sometimes the entire chest.
The difference in the radial pulse, as mentioned above,
a common sign in pulmonary tumor, will not aid in recog-
nizing an aneurysm unless the smaller pulse is found on the
side opposite to that to which all indications point as the
seat of the tumor. A. Frankel and others called attention
to the fact that lung tumors usually cause a paralysis of both
recurrent laryngeal nerves, while in the ordinary forms of
aneurysm of the arch of the aorta it is only the left laryn-
geal recurrent that is affected. Only in exceedingly rare
cases, in cases of enormous size of the aneurysm or of mul-
tiple aneurysms, has paralysis of both laryngeal nerves been
observed.^ As the case proceeds, secondary visible or pal-
» Baumler, Deut. Archiv. f . klin. Med., Vol. II, p. 563.

CLINICAL (Continued) 105

pable tumors, the usual characteristics, etc., will assure the
diagnosis of tumor, to the probable exclusion of aneurysm.
The tendency for the spreading and enlargement of aneurysm
is natm-ally more toward the left than toward the right side.
This fact may occasionally be of some use in diagnosis.

Stokes and Graves mentioned a certain asymmetry of
the thorax in cases of malignant neoplasm of the lung.
A. Frankel and others have in recent times called attention
to this as an almost pathognomonic symptom. The asym-
metry consists in the retraction of that side of the chest
where the tumor is supposed to be localized, especially in its
posterior and lateral aspects, after tapping of the pleuritic
effusion. This ^'r^tr^cissement thoracique" is supposed to
be caused by the rapid involvement of the pleura, with its
consequent thickening, by which the proper expansion of
the lung is prevented.

As a curiosity which does not occur very frequently, but
which, when it does happen, can hardly be distinguished
from primary malignant tumor of the lung, see the case of
Boris. ^ In this case there were all the symptoms from which
a diagnosis of primary malignant neoplasm of the lung could
have been made, though the clinical diagnosis was tuber-
culosis. At autopsy no positive anatomical diagnosis was
attainable and it was only through microscopic examination
that the tumor was found to be chorionepithelioma, the
primary focus being an insignificant and easily overlooked
spot in the broad ligament. The case of Couvelere ^ may
also be mentioned as one of those congenital cystadenoma-
tous structures which might occasionally be confounded with
primary malignant tumor. A glance at some of the other
cases recorded in Table IV will show a number of instances
of congenital adenomatous, cystic, and some secondary,
tumors of the lung which might be confounded with pri-
mary malignant neoplasms, and in many cases the differ-
ential diagnosis will be almost impossible. There are some
of particular interest, as the case of Dionisi,' the case of

» Table IV, No. 1. » Table IV, No. 6.

» Table IV, No. 7.

106 PRIMARY MALIGNANT GROWTHS OF THE LUNG

Lesieur et Rome.^ In the latter there was a large massive
cyhndrical celled typical carcinoma in the lung, where only
a careful autopsy showed the primary focus to be a very
insignificant nodule in the rectum. The tumor in the lung
had precisely the character of the rectal cancer and is further
remarkable for the fact that it is the only secondary tumor
of the lung on record which consists of one large massive
growth. The case of Laseque ^ is also to be noted as a case
of lympho-sarcoma, where the primary focus could not posi-
tively be determined, but may have been in the lung, and
the case is remarkable for the very unusual generalization
of the lympho-sarcoma simulating a primary tumor. The
cases of dermoid tumor of the lung, — that of Sommers ^
and Sormani,^ — though they may in many respects, for a
time at least, be mistaken for primary malignant neoplasm
of the lung, will soon appear in their true nature by the
expectoration of hair and other dermoid components.
Of great interest, also, is the case of Linser,^ which might
easily have been mistaken for a malignant tumor of the
lung, but which on autopsy turned out to be a congenital
cyst-adenoma of the lung with a profuse production of
mucus. Boecker,^ when presenting his interesting case of
the production of mucus in a case of carcinoma of the lung,
speaks also of the cases of Lohlein^ and Helly.^ He be-
lieves that Lohlein's case is a genuine case of carcinoma with
profuse production of mucus. The character of Helly's
case is not yet satisfactorily determined. There is also to
be mentioned the case of Jores.^ In this case a dermoid
cyst of the left lung was connected with a maUgnant
cysto-sarcoma. It is not necessary to go into the details

1 Table IV, No. 13.

2 Table IV, No. 12.
» Table IV, No. 17.
* Table IV, No. 18.

^ t)ber einen Fall von congenitalem Lungen-Adenom, Virch. Archiv., No.
157, p. 281.
^ Loc. cit.

7 Table IV, No. 14.

8 Table I, No. 122.

® tlber die Verbindung einer Dermoidcyste mit malignem Cystosarcom
der linken Lunge, Virch. Arch., No. 133, p. 66.

CLINICAL (Continued) 107

of the case. There seems no doubt that the sarcoma was
developed secondary to the congenital dermoid cysts.

It is customary, in the study of any clinical subject, to
conclude with a careful discussion of the treatment. The
treatment of primary malignant growths of the lung has not
required much discussion in the textbooks up to date, and
if mentioned at all is finished off with one or two lines.
The diagnosis of a cancer of the lung was the death-warrant
of the patient. In former times, before medicine determined
to become one of the natural sciences, the patients were
treated, not for cure, but for relief, by all sorts of barbarous
means. It is about one hundred years ago that Heyf elder, ^
disgusted with the treatment that these unfortunates were
receiving under all sorts of diagnoses, — the blood-letting,
the purging, the salivation, etc., — urged upon physicians
the necessity of recognizing these cases as cancer and as
hopeless, and begs them not to add the torture of medical
treatment to the sufferings consequent upon the disease
itself. "Optima hie est medicina, medicinam non facere."
Present-day medicine treats these cases purely symptomat-
ically with the sole object of relief, and the interest attaching
to an accurate diagnosis is mainly theoretical and scientific.
It is not to be wondered at that the physician takes little
interest in types of diseases that offer not the slightest hope
of therapeutic success. It cannot really, he thinks, if he
thinks at all, make any difference to the patient if he is to
die of a pulmonary phthisis or of a far advanced pulmonary
cancer. It is not very many years ago that Benda^ was
justified in asserting that cancer of the lung occupied a
unique position, inasmuch as it was the only cancer that
was absolutely beyond the reach of the surgeon; but he
went a step further and added that no matter what progress
surgery might make, it could never hope to deal satisfactorily
with lung cancer, as it would always remain impossible to
make the diagnosis early enough for any reasonable expecta-

* Loc. cit.

^ Zur Kenntniss des Pflasterzellenkrebses der Bronchien, Deut. Med.
Wochenschr., 1904, p. 1454.

108 PRIMARY MALIGNANT GROWTHS OF THE LUNG

tion of a cure by surgical interference. This is a practical
illustration of how unwise it is to attempt to set hmits to
the progress of science. Since Benda made this daring state-
ment, matters have completely changed. The technique
of thoracic surgery and especially of lung surgery, — thanks
to the efforts of Brauer,^ Friedrich,^ and Garre and Quincke, ^
and in a more practical maimer the efforts of Sauerbruch,
Willy Meyer, Meltzer, and Lenhartz, — though evidently
still in its beginning, has already developed to a marvellous
degree. Lenhartz ^ succeeded in operating several cases
of cancer of the lung, and in one case, to all appearances
desperate and hopeless, by removing the affected lobe in
its entirety, prolonged the patient's life for a year and a
half, and with comparative comfort. There is every reason
to hope that the technique of this new branch of surgery
will be still fiuther developed and that in the near future
thoracotomy and operations on the lungs will be attended
with no more risk than are peritoneal operations to-day.
If this is so, a new and great responsibility is placed upon the
shoulders of internal medicine. It will be necessary, not
only to educate the opinion of the laity so as to induce them
to submit to these operations with the same readiness with
which they now submit to peritoneal operations, but it will
also be the sacred duty of the physician to recognize these
cases and to recognize them as early as possible. The physi-
cian must be imbued with the conviction that malignant
pulmonary disease occurs much more frequently than is
commonly beUeved and that he may meet it any day in his
practice among the young, as well as among the old. As at
present the conscientious physician examines every chest
for possible tuberculosis, so in the future every chest will
have to be examined for possible tumor. The writer would
go still further. Where all the means of diagnosis outlined
in this httle study fail, where there is suspicion of tumor,

^ Referat uber Lungenchirurgie, Verhandl. der Gesellschaft Deut. Natur-
forscher und Artze, September, 1908.

* Die Chirurgie der Lungen, Archiv. f. klin. Chir., 1907, Vol. 82, p. 1147.

* Grundriss der Lungenchirurgie, Jena, 1903.

* Conf . the various pubhcations of the Hamburger Staatskrankenhaus.

CLINICAL (Continued) 109

but no assurance is possible, there should be, — it is emphat-
ically here stated, — as httle hesitation in resorting to an
exploratory thoracotomy as there is nowadays in submitting
to an exploratory laparotomy. A very few cases have been
treated in this way.^ The writer himself has had occasion to
advise exploratory thoracotomy in two cases, but neither
the physicians nor the lay pubUc are as yet educated up to
the proper point of view, and both cases preferred to die of
cancer without an attempt at cure or relief. But even in
cases far advanced, where there is apparently no hope what-
ever and death seems imminent, a thoracotomy may, under
certain conditions, be indicated. It is obvious that no one
would think of operating on the very aged, with predominant
brain symptoms, or in any case where the lung symptoms
are more or less in the background; but a thoracotomy, with
a possible resection of one or two or three ribs, by draining
off continually recurring effusions, by the decompressing
effect produced thereby, quite similar, in fact, to the opera-
tions now performed for brain tumor, may give reUef and
produce euthanasia, in the place of otherwise unspeakable
torture.

In conclusion, the writer may be permitted to express the
hope that malignant disease of the lungs, so disastrous in its
results, may perhaps in the near future be summarily dealt
with in its incipiency, or at least modified in its progress, so
as in some measure to assist in diminishing the sufferings of
humanity. The writer's ideal hopes will be fulfilled if this
essay contributes in ever so small a degree to this result.

1 Miiser, Table I, No. 208; Benda, loc. cit., and a few others.

APPENDICES

Carcinoma — Duration

Not stated 226

No autopsy 1

Doubtful 1

"Several years" 1

6 years 2

4 years 2

3 years 1

2| years 2

2 years 7

1^ years 6

1^ years 3

1 year 16

11 months 1

10 months 7

9 months 9

8 months 4

7 months 9

6 months 15

6^ months 4

6 months 11

4| months 1

4 months 4

3| months 1

3 months 15

2| months 2

2 months 10

"Several months" 1

li months 5

5 weeks 3

3 weeks 2

2 weeks 2

374

Sarcoma — Duration

Not stated 48

6 years 1

3\ years 1

3 years 2

Between 2 and 3 years 1

2f years 1

2 years 2

22 months 1

16 months 1

15 months 1

1 year 4

11 months 1

10 months 2

9 months .- 2

8 months 1

6 months 2

6 months 4

4 months 4

3^ months 1

3 months 3

21 months 1

2 months 3

1| months 2

1 month _1

Carcinoma
METASTASES
Lymph Nodes

Bronchial lymph nodes 117

Mediastinal lymph nodes 45

Tracheal lymph nodes 26

Cervical lymph nodes 23

Retroperitoneal lymph nodes . 23

Hilus nodes 16

Regionary lymph nodes 15

Axillary glands 15

Mesenteric glands 14

Supraclavicular 13

Peribronchial 6

Inguinal glands 3

Posterior mediastinal 2

Peritracheal 2

Clavicular 2

110

APPENDICES

111

Epigastric glands 2

Portal glands 2

Subclavicular

Glands of neck

Glands of chest

Subdiaphragmatic glands

Substernal

Perigastric

Retrogastic

Periaortic

Thoracic glands

Peritoneal glands

Parotid glands

Lumbar

Celiac

"Lymph nodes" not specified .

Liver 103

Gall-bladder

Left Lung . .
Right Lung .
Both Lungs .
Root Lungs .

Pleura

Right Pleura

Left Pleura

Pericardium

Heart . .

39
0

Left Ventricle

Right Ventricle

Left Auricle

Right Auricle

Myocardium

Interventricular Septum of
Heart

3
3

Origin Aorta

Large Vessels

Pulmonary Veins

'?,

Lower Cava

Both Kidneys

Left Kidney

32
15

Right Kidney

Left Suprarenal

Right Suprarenal

Both Suprarenale

Spleen

14
17

Capsule Spleen

Pancreas

Thyroid

1*;^

Brain

Dura Mater

Corpus Striatum

Cerebral Hemispheres

Hypophysis

Medulla

Cerebrum

Spinal Cord

Nerves (Left Vagus) .

Peritoneum

Intestines

Ileum

Diaphragm

(Esophagus

Stomach

Pylorus

Gastro-hepatic Ligament . . .

Mediastinum

Posterior Mediastinum ....

Bladder

Right Testicle

Uterus

Ovaries (1 Left)

Skin

Left Eye

Left Leg

Finger-tip . . . .
Tip of Nose . .
Nasal Septum

Skeleton

"Bones"

Skull

Frontal Bone
Parietal Bone

Sternum

Clavicle

Chest Wall . .

Ribs

Upper Ribs . . .

1st to 7th

5th rib

6th rib

7th to 8th

Vertebrae

Dorsal

3d dorsal

7th to 8th dorsal

3d cervical

7th to 10th

Lumbo-sacral . . .

10
1
1
1
1
1
2
1

7
1
1
6
3
4
1
1
4
1

112 PRIMARY MALIGNANT GROWTHS OF THE LUNG

Femur

Right Humerus
Long Bones , . .
Iliac Fossa ....
Shoulder Joint

Muscles

Intercostal

Trunk

Back and Abdomen

Chest

Back

Not Specified

No Metastases

Metastases not Mentioned

Sarcoma

METASTASES

Lymph Nodes

Bronchial

Mediastinal

E-etroperitoneal

Axillary

Cervical

Peribronchial

Hilus

Inguinal

Posterior mediastinal

Regionary

Mesenteric

Infraclavicular

Supraclavicular

Retrobronchial

"Lymph nodes"

Various

Liver

3
1
1
1
1
2
33
57

15
10
5
5
4
3
3
2

Right Lung

Left Lung

Side not Specified

Pleura

Pericardium . . .
Heart Muscle .
Left Ventricle
Left Auricle . .
Right Auricle .
Auricles

Brain

Spinal Dura . . . .
Spinal Cord . . . .
Left Recurrent

Anterior Mediastinum

Diaphragm

Hepato-duodenal Ligament

Pancreas

Spleen

Peritoneum

QilSOPHAGUS

Kidneys

Right Kidney

Left Kidney

Skin

Lower cava

Vertebrse

Right iliac

Left shoulder

Scapula ; .

Ribs (2, 3, 4)

(9, 10, 11)

Right humerus

Humerus (side not stated) .

No Metastases

Metastases not Mentioned

24
15

Note. — It was found practically impossible to classify the metastases accord-
ing to a uniform system. They were, therefore, recorded as reported by the
authors and grouped as nearly as feasible according to the various organs and
tissues affected.

TABLES

114

TABLE I

Adleb

Abler

LUNG IN-
VOLVED

Adleb

4 Abler,
I Packard, M.,

Med. News, Feb. 18,
1906

Adleb

CLINICAL SYMPTOMS

Admitted to hospital in moribund
condition with symptoms interpreted
as pulmonary phthisis. No history
obtainable

In hospital for 3 weeks. For 3
months cough and pain in right chest.
Progressive loss of strength and flesh,
anorexia and nausea. Flatness and
absence of voice and breathing over
greater part of right lung. 800 c.c. of
bloody serum aspirated from right
pleura. Irregular fever up to 102.
Acetone in urine. Haemoglobin 65;
reds 4,500,000; whites 15,000

No heredity. Inveterate smoker.
Stout, healthy-looking. Harassing
cough, pain in left upper chest,
dyspnoea on slight exertion. For
several years repeated profuse haemop-
tysis. Flatness, absence of voice and
breathing over left anterior chest. No
fever. Sudden death from profuse
haemoptysis. Approximate duration
of disease about 4 years

No heredity. For 6 years cough
and pain in right chest. Had periods
where cough and pain would disappear.
For 2 years cough permanent a,nd
more harassing; gradually increasing
dyspnoea. Veins over chest and upper
abdomen enormously dilated and
tortuous. Complete flatness, absence
of voice and breathing over anterior
right chest. No bulging. Occasional
profuse haemoptysis. Haemoglobin 62 ;
red cells 3,980,000; white cells 14,300;
lymphocytes 24%. Later enlarge-
ment of axillary and supraclavicular
lymph nodes. 600 c.c. clear serum
aspirated from right pleura. Death
in a hansom-cab from haemoptysis

Father died of cancer of stomach.
Patient always in good health until
about I2 months before admission.
Pain in right chest; no cough; no
expectoration. Increasing debility.

CARCINOMA

115

AUTOPSY NOTES

Scant,
muco-
punilent,
at times
bloody,
no tuber-
cle bacilli
or tumor
elements

Muco-
purulent,
some-
times
bloody
for weeks,
no tuber
cle bacilli
or tumor
elements

None at
first, then
muco-
purulent
and re-
mains
bloody;
no tuber-
cle bacilli
or tumor
elements

None

Heart dislocated to right;
right lung normal. Sanguin-
olent effusion in left pleura;
pleura much thickened. In
upper left lobe a tumor size
of two fists with cavity in
centre

Medullary carcinoma

METASTASES

Region-
ary lymph
nodes, liver,
both kidneys
and spleen

Large tumor involving
upper portion of lower and
lower portion of upper lobe
of left lung, containing an
irregular cavity filled with
blood and broken down
tumor material, and into
which stumps of vessels and
bronchi infiltrated with
tumor material still project.
The rest of left lung diffusely
infiltrated with tumor along
the track of the bronchial
ramifications

Tumor of the right main
bronchus extending to the
posterior portion of the left
bronchus. Tumor pene-
trates the right lung in all
directions to the pleura
along the track of the bron-
chial ramifications. Numer-

i bronchiectatic dilata-
tions. Compression of upper
cava, right pulmonary and
right innominate arteries

Right pleural cavity com-
pletely filled with huge
masses of old fibrinous blood
clot, and entire lung pushed
against posterior chest wall

Pericar
dium, heart
muscle, kid
neys, left
suprarenal,
bronchial
and medias-
tinal lymph
nodes

Pericardium,
bronchial,
mediastinal,
and retro-
peritoneal
lymph nodes
and liver

MICROSCOPE

Medullary
carcinoma

Pleural
surface of
right dia-
phragm,
pericardium,
regionary
lymph nodes
and left lung

It was practically
impossible in micro-
scopic examination
of the main tumor in
the left lung to say
whether we had to
deal with a round-
celled sarcoma or
with a carcinoma.
Only the study of the
metastases made the
diagnosis of carci-
noma absolutely cer-
tain

Typical car-
cinoma of
glandular
type

Epithelioma

Right
auricle, cer-
vical, medi-
astinal, and
bronchial

116

TABLE I

Adleb

Adleb,

Garbat, A. L.,
American Joum. of
Med. Sciences, 1909,
Vol. cxxxvii, p. 857

Adleb

Allan, Geo. A.,

Lancet, Oct. 6, 1907,
p. 961

Primary Cancer of
Left Bronchus with
Unusual Associa-
tion of Pressure
Symptoms: Sec-_
ondary Growth in
Thyroid and Lym-
phatic Glands

BEX AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Subsequently hoarseness, swelling of
right side of face, right chest, arm,
and foot. Impaired respiratory motion
of right chest. Flatness over right
chest except a rather large area pos-
teriorly where there is increased vocal
fremitus and some tympany on per-
cussion. Heart 8 cm. beyond left
mammillary line. Irregular areas of
bronchial breathing and dulness on
left chest. Tyrnpanitic area in right
chest steadily diminishes in size

No heredity. Harassing cough with
profuse mucopurulent, sometimes
bloody expectoration for some years.
Lately loss of weight and strength.
Pain and slight dyspncea on exertion.
Complete flatness, diminished voice
and breathing sounds to 4th rib on
right side. Diagnosis of tumor during
life

Loss of weight for over a year.

Cough, hoarseness, night sweats.
Impaired respiratory motion of right
chest with diminished voice and
breathing anteriorly, flatness pos-
teriorly. In November 150 c.c. bloody
serum withdrawn. No characteristic
elements. 6 weeks later increasing
dulness, high fever. Aspiration 60
c.c. chocolate-colored pus. Thora-
cotomy. 6 weeks later cholecystitis;
3 stones removed by cholecystotomy.
6 months later soft tumor over right
scapula; tumor excised; carcinoma.
Increasing weakness; death

Uncertain history of malignancy in
family. Always healthy; no syphihs.
For 2 months spitting of blood in the
morning. Increasing cough. Slowly
diminishing weight and strength at
first; later rapidly diminishing weight
and strength. Increasing pain in up-
per right chest; dulness over right
upper lobe; diminished breathing and
respiratory motion. 2 weeks before
death signs of cavity in apex.

No previous history; no syphilis.
DoulDtful heredity. Pain in left chest
radiating into shoulder and down left
arm. Increasing loss of strength and
weight; dyspnoea on slight exertion.
Hoarseness; harassing cough. Flat-
ness over greater portion of left chest
in front and behind, with absence of
voice and breathing, but distinct
transmission of heart sounds every-
where. No rales. Right chest nor-
mal. Hard mass above left clavicle.
Enlarged nodes in left neck and

CARCINOMA

117

Mucopuru-
lent, fre-
quently-
bloody,
no tuber-
cle bacilli

Profuse,
purulent,
bloody,
no tuber-
cle bacilli,
no tumor
cells

No tuber-
cle bacilli,
but very
numer-
ous large
"Korn-
chenzel-
len"(Len-
hartz)

Never
bloody,
no tuber-
cle bacilli

AUTOPSY NOTES

and compressed. Anterior
half of right lung completely
replaced by tumor. Right
auricle, pulmonary artery,
and upper cava compressed
by tumor. There are throm-
boses reaching into the right
internal jugular and sub-
clavian arteries

Confirmed diagnosis.
Records could not be ob-
tained

Right pleura and dia-
phragm thickened and ad-
herent. Middle and lower
lobe almost entirely replaced
by tumor. Bronchiectatic
dilatations

Cavity in right apex sur^
rounded by tumor extending
along bronchial vessels to
the hilus and to the pleura
Gray hepatization around
the tumor

Clear serum in right
pleura. Cancer encircling
left main bronchus from bi-
furcation downward and
obstructing its lumen. Bron-
chiectatic abscesses; throm-
bosis of left subclavian vein
Degeneration of left
recurrent

METASTASES

lymph
nodes

Both lungs,
liver, bron-
chial and
retroperito-
neal lymph
nodes

Right
pleura ; su-
praclavicu-
lar gland

Bronchial
and medias-
tinal lymph
nodes, left
pleura, peri-
cardium,
and left lobe
of thyroid

MICBOSCOPE

Cylindrical-
celled carci-
noma. Un-
doubted ori-
gin from bron-
chial mucous
glands

Squamous
carcinoma
probably
originating
from small
bronchus

Scirrhus
with unusua-
ly large cells
having ten-
dency to ne-
crosis

118

TABLE I

Anderson, J. W.,
Glasgow Med. Jour.,
1883, 146-148

Angelhoff,
.. Diss. Miinchen, 1905
tjber das primare
Lungencarcinom

Antze,

Diss. Kiel, 1903
(After Angelhoff)

ijber primaren Lun-
genkrebs

Aknal,

Gaz. des H6pitaux

1844, p. 78
Cancer gpitheloide du

Thorax, etc.

ASCHENBORN, M

Arch, f . Klin. Chirur.,
1880, 171

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

axilla. Intermittent fever up to 103.
Paralysis of left recurrent; left pupil
contracted; slight ptosis of left eyelid.
Local hyperhidrosis of right face and
head. Death 5 months after first
definite symptoms

Severe dyspnoea. CEdoema of upper
part of body, including face, chest, and
both arms. Superficial veins dilated.
Slight cough and expectoration. No
fever. Dulness on right chest from
clavicle to nipple; both bases dull,
with diminished respiration and voice

For 3 months cough, expectoration,
dyspnoea; some fever. Pain in left
chest; night sweats. Increasing
emaciation; impaired respiratory mo-
tion of left chest. Dulness to 5th
spinous process posteriorly; bronchial
breathing; a few rales. Flatness and
loss of breathing and voice at base.
Bloody serum removed several times
by aspiration. Clinical diagnosis: pul-
monary phthisis

Cough, expectoration, pain, jaun-
dice. No dulness. Temporary im-
provement. After 1 year dulness over
whole right lung; tjonpanitic percus-
sion note and amphoric breathing at
right base. Some fever. _ Intense
pain and dyspnoea. Clinical diag-
nosis: phthisis and gangrene of right
lung

While in perfect health sudden chill,
fever, sore throat, cough and symptoms
of bronchitis, diagnosed as influenza.
Soon after dyspnoea, aphonia, stenotic
respiration to right of sternum. Loss
of breathing sounds over lower lobe,
but normal percussion note. Left
lung normal. Later oedoema of face,
neck, and arms ; dilatation of veins of
right chest and abdomen. Subse-
quently effusion in right _ chest and
oedoema of lower extremities. A few
days before death respiratory murmur
is again heard over lower right lung.
Sudden death. Duration of disease
about 9 months

Sick more than 2 years. Right
chest expanded by tumor pushing
heart to left and liver downward.
Flatness, absence of breathing sounds,
extreme dyspnoea, cyanosis, and ca-
chexia

CARCINOMA

119

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

BEMARKS

No details

Fluid in both pleurse. Tu-
mor at root of right lung.
Compression of upper cava

No details

Not given

Author says:
"Tumor is probably
sarcoma, originating
from bronchial glands
at root." This seems
doubtful; more prob-
ably a bronchial car-
cinoma

Mucopuru-

Bloody fluid in left pleura.

No details

Alveolar

lent, no

Whole left lung retracted

structure.

bacilli

and compressed ; studded
with tumor nodules. Bron-
chi filled and surrounded
with similar tumors. Tu-
mor nodules over costal and
pulmonary pleura and dia-
phragm

voluminous
stroma, poly-
morphous
and typical
cylindrical
epithelial
cells; areas of
glandular ar-
rangement

Not stated

Cancer of right main

Bronchial,

Alveolar

bronchus and its branches.

mediastinal,

structure, ori-

Chronic pneumonia and

cervical, and

gin from sur-

bronchiectases; gangrene of

retroperito-

face epithe-

lung; compression of upper

neal lymph

ium of main

cava

nodes. Per-
foration of
cancerous
lymph
nodes into
oesophagus

Dronchus

Bloody

Serious effusion in right

Right lung.

Not given

Probably carci-

pleura. Tumor in right

bronchial.

noma of bronchus of

lower lobe with cavity in its

mediastinal.

right lower lobe

centre. Right main bron-

and cervical

chus obstructed by larda-

lymph nodes

ceous neoplasm, also bron-

and right

chus of lower lobe almost

kidney

completely occluded. Com-

pression of upper cava and

recurrent laryngeal

Not stated

Entire right lung except
a small remnant at apex
converted into tumor, erod-
ing several ribs. Tumor
contains several large cysts
filled with dark fluid. Ev-

None

Not given

Tumor is called
cysto-carcinoma of
lung

erything else in body normal

120

TABLE I

AUFRECHT,

Nothnagel Handbuch
d. Spec. Path. u.
Therapie, Vol. XIV,
1st Ed., 1899, p. 370 ff.
Das Lungencarcinom

Loc. err.

Loc. CIT.

AtTGIEH, G. AND

Desplats, N.,
Journ. de Soc. Med
de Lille, 1883

AirVAED,

Biillet. Soc. Anat. de
Paris, 1882, 9&-99

LUNG IN-
VOLVED

Bargtjm,

Diss. Kiel, 1897

Ein Fall von primarem
Krebs der Trachea
und des rechten Bron-
chus

Baeth, H.

Le Bull. M6d. Paris,
1902, Vol. XVI, Pt
2, p. 757

clinical symptoms

Dulness over right middle and lower
lobe. Diminished breathing; loss of
fremitus. No fever. Nutrition good.
Dyspnoea on exertion. Aspiration
negative. Increasing weakness. Dura-
tion of disease 14 weeks

Father died of cancer of stomach.
Patient always healthy. Commenced
with cough and dyspnoea; later effu-
sion in left pleura. Aspiration 2300
c.c. bloody serum; breathing becomes
better; dulness remains. Sudden
death from pulmonary oedoema. Dura-
tion about 1 year. Clinical diag-
nosis: pleurisy

For 8 months " inflammation of lung
and pleura." For 4 months dysp-
noea. On admission immediate resec-
tion of ribs with discharge of 3000 c.c.
of pus from right pleura. No relief
after operation. Increasing stridor and
dyspnoea. No fever. Enlargement
of supraclavicular glands. Tumor
size of apple in liver. Paralysis of
right vocal cord. Death 26 days after
operation. Diagnosis made during
life

Fever, dyspncEa, dysphagia, pain
in chest. Flatness to 3d interspace;
absence of breathing

Sick 5J months. Dyspnoea, pain in

left chest. Dulness over entire left
side. Diminished fremitus; absence
of breathing at base ; further up harsh
bronchial respiration. Heart dis-
placed toward right. No cachexia.
Later anorexia; some fever toward
evening. Chest aspirated without
result. Later cedoema and albuminuria

No heredity. 6 weeks after re-
covery from some acute disease with
cough and fever, swelling of face and
neck, later of chest. Dyspnoea and
cough especially after eating. Cyano-
sis. Area of dulness with diminished
voice and breathing over right lower
chest. Nothing else on lungs. Some
effusion in right pleura

Small, poorly nourished woman.
Repeated attacks of bronchitis. Pres-
ent illness began only 5 days before
admission with cough, fever, and chill.

CARCINOMA

121

AUTOPSY NOTES

METASTASES

MICROSCOPE

Mucopu-
nilent,
mixed
with
blood

Not stated

Occasion-
ally
bloody

Bloody

Not stated

None

Abundant,'
purely
mucous,
no blood.

Diffuse medullary carci-
noma in lower portion mid-
dle lobe

Left lower lobe converted
into a firm tumor in which
only the larger bronchi can
be distinguished; centre
broken down

Carcinoma probably of
right main bronchus ob-
structing trachea and bron-
chus

Mediastinal
lymph nodes

Liver

Not given

Mediastinal
and tracheal
lymph nodes
and liver

Not given

Upper right lobe almost
completely replaced by soft
cheese-like tumor. Pleura
thickened; bronchi com-
pressed. Remainder of
right lung pneumonic hepa-
tization

Entire left lung one mass
of white encephaloid tumor
containing many cavities.
Granulated tumor on peri-
cardium

Beginning of right main
bronchus and wall of trachea
infiltrated with tumor. Sec-
ondary bronchus also oblit-
erated by tumor. Bronchi-
ectatic cavities in right lower
lobe. Compression of right
jugular, innominate, and ax-
illary veins, also upper cava.
Abundant effusion in right
pleura

Right lung healthy except
old and healed tubercular
foci in apex. Left pleura
adherent and whole left lung

Bronchial
and tracheal
lymph nodes

Mediastinal
and bron-
chial lymph
nodes

Regionary
lymph nodes

Not given

Tumor sim-
ply desig-
nated as
encephaloid
cancer

No details

Tumor simply des-
ignated as cancer

Absolutely
not a second
ary deposit
throughout

Alveolar
structure ;
polymor-
phous epithe-

Remarkable points
about this case are
the pleurisy with
little effusion, the

122

TABLE I

Cancer primitif oblit6-
rant de la grosse
bronche gauche; _
Bronchopneumonie
tuberculeuse du Pou-
mon correspondent

"24

Beale,

Med. Times & Gaz.,
London, 1869, II, 382

Beattftim^,

Bull, et M6m. de la
Soc. Anat. de Paris,
1902, Jom., IV, No. 7,
p. 664

Cancer massif primitif
du Poumon avec Le-
sions multiples

Beck, Hugo,

Zeitschr. f. Heilk.,

Vol. V, 1884, p. 459.

(Path. Festschrift,

Prag)
Zur Kenntniss des pri-

mS,ren Bronchialkreb-

Log. ciT.

Not
stated

LUNG IN-
VOLVED

M 65

CLINICAL SYMPTOMS

4 days before admission pain in left
chest. On examination impaired res-
piratory motion of left chest; slight
dulness at base ; feeble respiration and
pleuritic friction. Fine rales over
whole of chest. Fever up to 40° C.
Diagnosed as grippe (which was then
epidemic) with pleuritic complications
and the possibility of tuberculosis.
Next day everything improved except
left lung, which remained the same.
Puncture over left chest withdrew
clear serum without tumor elements,
tubercle bacilli, blood, or lymphocytes.
Later severe pain over left nipple,
intense dyspnoea, high fever, diarrhoea,
and vomiting. Later series of severe
chills and hectic fever. About month
after admission retraction of left chest,
marked dyspnoea, much cough, rapid
emaciation. Later absolute absence
of voice and breathing; flat percus-
sion note; later cyanosis and signs
of cavity in left upper lobe. Death
about 3 months after admission to
hospital

Loss of flesh, pain in left chest,
profuse perspiration; dry cough. Flat-
ness over left chest; no fremitus.
Heart displaced ; some bulging of
lower intercostal spaces. Dilatation
of superficial veins. Progressive in-
crease of dulness ; increasing cachexia.
Later painful secondary tumor in left
axUla

Old syphilitic with tertiary lesions.
Large liver, dyspnoea, cachexia. Bloody
effusion in right pleura. Rapid de-
velopment in 3 months. Clinical
diagnosis: cancer of liver with in-
volvement of lung and pleura

No details

Clinical diagnosis: tumor of right
pleura

CARCINOMA

123

AUTOPSY NOTES

no tuber- consolidated and much
cle bacilli smaller than normal. Lower
lobe atrophic and retracted
Blood and pus flow from
trachea on taking out lung
3 cm. below bifurcation a
round soft tumor arises from
wall of left main bronchus,
almost completely obstruct-
ing bronchus. The whole
left lung like a sponge filled
with pus is a series of small
round tumor areas sur-
rounded by lung tissue ap-
parently not much altered —
some solid some softened and
broken down in centre, alto-
gether like tubercular foci.
Bronchial tumor is not ul-
cerated but is surrounded by
apparently healthy mucous
membrane; penetrates down
to cartilage

None

No details

METASTASES

the entire
body, not
even bron-
chial or tra-
cheal glands

Entire left lung occupied
by tumor; only a thin shell
of lung tissue remaining be-
hind and at base

Liver merely congested.
Cancer right lower lobe.
Aneurysm of descending
aorta; thrombosis azygos

Medullary tumor of right
main bronchus and its rami
fications. Bronchiectatic di-
latations and lobular pneu-
monic consolidation in right
lung, also some tubercular
granulations. Upper cava
compressed and infiltrated
by tumor

Cavity in right upper lobe,
walls infiltrated with cancer.
Medullary cancer in right
main bronchus and branches
obstructing lumen. Neo-
plasm extends through lung
along bronchial ramifica-
tions directly into cavity.
Infiltration and compres-
sion of upper cava and vena
azygos

Bronchial,
retroperito-
neal, and su-
praclavicu-
lar lymph
nodes, axilla,
and pericar-
dium

Diaphragm,
pericardium,
and medias
tinal lymph
nodes

Bronchial

nodes at
hilus

MICROSCOPE

lial cells.
Origin from
bronchial
mucous
membrane.
The foci in
lung are
proven to be
tubercular,
consisting
mainly of typ-
ical tubercles
in all stages
of develop-
ment and
degeneration

complete atelectasis
of lung, and the tu-
bercular afifection of
one side only

No details

Right bron-
chial lymph
nodes,
pleura, thy-
roid, liver,
both supra-
renals

No details

Alveolar
structure ;
spindle celled
stroma

Author thinks
tumor spread along
bronchial ramifica-
tions and believes
that thoracic duct
was involved

Origin from bron-
chial mucous glands

Alveolar
structure ;
large epithe-
lial cells with
frequent mu-
coid degener-
ation

Origin from bron-
chial mucous glands

124

TABLE I

NO.

AUTHOR

SEX

AGE

LTTNG IN-
VOLVED

CLINICAL SYMPTOMS

Begbie, J. Wahburton
Archiv. of Med., II,
London, 1860-61, p.
145

Case of Mediastinal and
Pulmonary Cancer

Always healthy. Cough, husky
voice, intense dyspncsa; rapid emacia-
tion. (Edcema right face, neck, arm,
and over upper sternum. Dulness to
2d rib; diminished respiratory motion
and fremitus. Feeble, stridulous,
highly bronchial respiration. Tap-
ping of chest gave temporary relief.
In 23 days was tapped 10 times, total
amount of clear seruin being 550
ounces. Duration of disease about
6 weeks

Behiee,

Hop. de la Petie, Gaz.
des Hop., 45, 1867

Cough, headache, vomiting, fever.
Emaciation, intense dyspnoea, neural-
gia in right arm. Right chest 3 cm.
larger than left. Dulness with tubular
breathing and amphoric voice on
right upper chest. Enlarged glands
over right clavicle

Belcher, W. N.,

Brooklyn Med. Jour.,
Vol. V, 1901, p. 703

Primary Carcinoma of
the Lung

Always in good health until attack
of "grippe pneumonia." Effusion in
left pleura; aspiration withdraws
seropurulent fluid. Patient improved,
but there was an early recurrence and
several more aspirations were neces-
sary. One week before death a
nodule appeared under the skin on the
anterior of left chest

Benkert,

Diss. Freiburg. No

date
Das primare Lungen-

carcinom

Pain about sternum; increasing
dyspnoea and cyanosis. CEdoema of
upper part of body, especially left
arm. Dilatation of veins of chest.
Left limg normal. Flatness over
upper right chest; dulness below.
Bronchial respiration. Enlargement
of axillary lymph nodes

Benkeet,
Loc. cit

Burning pain in right arm and neck.
Cyanosis of face, ffidoema of neck and
both arms. Clubbed fingers. Dul-
ness posteriorly from 2d dorsal to
angle of scapula. Below clavicle
anteriorly, bronchial respiration

Benkert,
Loc. cit.

No clinical history

CARCINOMA

125

AUTOPSY NOTES

METASTASES MICROSCOPE

None

No details

Bloody,
contains
spirals
and nu-
merous
large epi-
thelial
cells

No tubercle
bacilli,
numer-
ous epi-
thelioid
cells

No details

Large " encephaloid " can
cer under upper f of ster-
num involving nearly all of
right upper lobe and ob
structing main bronchus.
Compression of upper cava
and large thoracic veins

Irregular nodular, hard,
white tumor, size of fist in
right middle lobe

Bloody fluid in left pleura,
thickening of left pleura,
pericardium, and left half of
anterior mediastinum with
hard nodular tumor masses
connecting directly with
nodule under the skin.
Entire anterior left lung
infiltrated with hard white
tumor

Bloody serum in right
pleura and in pericardium
In mediastinum a tumor ex-
tending downward to the
right, which involves right
upper lobe. Compression
of right auricle; thrombosis
of jugular veins; compres-
sion of innominate and sub-
clavian, also trachea

No details

1000 c.c. clear serum in left
pleura. Right apex firmly
adherent to ribs by tumor
masses which extend
through lung and penetrate
trachea immediately above
bifurcation

Upper part of left lung ex-
tremely soft tumor, nodu-
lated with fibrous strands
between nodules. Erosion
of 2d to 5th dorsal verte-
brae by neoplasm

Right
pleura,
glands of
neck, medi-
astinal
lymph
nodes com-
pressing
trachea

Bronchial
glands,
pleura, and
pericardium

"Distinct
cancer cells"

Probably bronchial
carcinoma

Axillary
lymph
nodes,
tracheal,
bronchial,
mediastinal,
and mesen-
teric lymph
nodes.
Pericardium
left supra
renal. Small
nodule, 2 cm
in diameter
in ileum

Tracheal
and bron-
chial lymph
nodes

No details

Author
states that
tumor con-
tains typical
cancer cells

Scirrhus
with cuboidal
cells

Typical
medullary
carcinoma

T3T)ical
pavement
epithelium

No details

It is probable that
the small tvmaor in the
ileum was primary

126

TABLE I

Benkeet,
Log. cit.

Bennett, J. Hughes,
Edinburgh, 1849, p
43

Cancerous and Can-
croid Growths

Beenheim and Simon,
Revue M6d. de I'Est
Nancy, 1886

Bernstein, A.,
Diss. Miinchen,
1909

Zur klinischen Diag-
nose des primaren
Lungencarcinoms

LUNG IN-
VOLVED

Betschaet,

Vircho"ws Arch.,"

.. 142, 1895

Uber die Diagnose
mahgner Lungentu-
moren aus dem Spu-
tum

Bevacqua, a.,

Giornale internazio-
nale delle Scienze Me-
diche, 1904, p. 625

Sul Carcinoma cilin-
drico primitive del
Pulmone

CLINICAL STMPTOM8

No clinical history

Pain, dry cough, dyspnoea. Left
chest less voluminous than right.
General dulness over left chest. Flat-
ness below clavicle. At apex bronchial
respiration; below faint and dimin-
ished. Increasing emaciation and
cachexia

Pain, radiating into arm and back.
Dyspnoea; effusion in right chest.
By aspiration 2000 c.c. of clear serum;
smaller quantities are subsequently
aspirated, later becoming hsemorrhagic

History of lues and urinary troubles.
Well until 5 years before admission,
when urinary difficulties began. Three
weeks before admission painful mictu-
rition, feeling of great weakness,
fever, much cough, stabbing pain in
chest, mmabness in both hands.
Right apex slightly dull; many rales.
Later dulness left base with diminished
respiration. Albumin in urine. Clini-
cal diagnosis: tabes dorsalis, phthisis
pulmonalis; neoplasm. Death about
5 weeks after admission

No clinical history

No heredity. Slight dulness, in-
creased vocal fremitus and some moist
rales in right subscapular region. All
the rest of lung normal. No fever;
very little cough at first. History of
syphilitic infection. Pain for about
a year, particularly in arms, head, and
tibiae. Increasing cough_ and expec-
toration; fever and night sweats.
Pain at right base; signs of cavity in
lung. Diarrhoea. Clinical diagnosis:
tuberculosis

CARCINOMA

127

BPUTTJM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMABE3

No details

Tumor at hilus of left lung

Lymph

Pavement

Author considers

adherent to pericardixmi.

nodes

celled carci-

the alveolar epithe-

Right lung normal

noma

lium the starting
point of the main tu-
mor in the last 3 cases

No details

Upper left lobe dense
yellowish-white tumor size
of a large orange. Isolated
nodules of cancer in left lung
surrounding large bronchial
tubes. Heart, right lung,
and all other organs normal

Bronchial
glands and
pericardium

No details

One small

Chocolate colored fluid in

Left pleura

Merely

hgemop-

right pleura. Right lung

and perito-

stated that it

tysis

infiltrated throughout with

neum, both

is medullary

firm, white tumors; bron-

of which are

cancer

chiectatic dilatations

studded
with small
nodules like
tubercles

Abundant,

Simply says carcinoma of

Left peri-

Carcinoma

mucoid,

left lower lobe. A typical

bronchial

simplex (sic)

no tuber-

catarrhal hsemorrhagic

glands and

originating

cle bacilli

pneumonia

in liver

from bron-
chial mucous
membrane

Sputum

Cancerous infiltration of

Right upper

Cylindrical

Bronchial surface

contained

right lower lobe ; also a sep-

lobe and

celled carci-

epithelium stated aa

numerous

arate nodule not sharply

corpus stri-

noma

starting point

epithelial

bounded. Lymphatics large-

atum of the

cells from

ly injected with tumor

brain

which di-

masses

agnosis

of tumor

was made

during

life

At first

Left lung normal; right

Bronchial,

TjT)ical cylin-

scant,

lung adherent; grayish infil-

subclavicu-

drical celled

later

tration in centre of lower

lar glands

carcinoma.

abund-

lobe in which pulmonary

and kidneys

which author

ant, never

structure is no longer dis-

considers as

tubercle

cernible. Cheesy deposits

originating

bacilli

broken down and forming
cavities surrounded by nu-
merous miliary nodules.
Bronchial glands enlarged;
contain cheesy deposits,
miliary nodules; some dif-
fusely infiltrated. Anatom-
ical diagnosis : tuberculosis
of bronchial glands of lower

from bron-
chial mucous
membrane

128

TABLE I

NO.

ATTTHOB

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Beveeidge,

Medical Press & Cir-
cular, June 2, 1869

Case of Sudden Death

Slight cough; pressure over chest.
Able to work until death. Sudden
death from haemoptysis

BiRCH-HlRSCHFELD,

Arch. f. Heilkunde,

19, 1878

(after Reinhard)

Cough, dyspnoea, weakness and ema-
ciation; insomnia. Dulness over right
upper lobe ; rough breathing in front;
bronchial breathing behind right upper
lobe ; rales. CEdoema and dilated veins
of upper part of body. Glands over
both clavicles enlarged to size of fist.
Left lung normal

Blumenthal,
Diss. Berlin, 1881
(quoted after Fuchs)
Zwei Falle von pri-
maren malignen Lun-
gentumoren

Repeated haemoptysis; increasing
dyspnoea. Gradually increasing dvil-
ness over whole of left lower lobe with
bronchial respiration and increased
vocal fremitus; later bulging of left
lower chest. _ First aspiration no fluid ;
later aspiration effusion which later
becomes bloody and under the micro-
scope contains tumor particles. Fre-
quent aspirations become necessary;
repeated attacks of haemoptysis

Borx, Emile,

Soc. Anatomique de
Paris, 1891, p. 398

Cancer primitif du Pou-
mon gauche, etc.

No previous history. Patient on
admission pulseless; cedoema of lower
limbs; arrhythmia. Extensive peri-
cardial dulness; flatness and absence
of voice and breathing over both sides
of chest posteriorly

BOTESATO,

Diss. Berlin, 1863

De Carcinomate Pul-

monum et Pleurae

For 5 years dyspncsa and palpitation
on slight exertion ; more recently ema-
ciation and weakness, increasing dysp-
noea, and severe pain in left chest. Dul-
ness and impaired respiratory motion
over whole of left chest; bronchial
breathing over upper portion; dimin-
ished voice and breathing over lower
portion. Right lung normal. Mitral
regurgitation. 2000 c.c. bloody fluid
aspirated from left chest

B6TTGEH,

Miinch. med. Woch.,
1902, p. 272
Ein Fall von primarem
Lungencarcinom

Oppression in right chest soon fol-
lowed by cough, pain, fever. Right
lower base: dulness, rales, diminished
breathing. Diagnosis influenza. Six
months later increased dulness involv-
ing the entire lower lobe posteriorly;
slight bulging appears ;_ impaired res-
piratory motion, diminished fremitus.
Progressive loss of strength and weight.
Increasing dyspnoea, cachexia and pain.
Death about 2 years after first com-
plaint

CARCINOMA

129

AUTOPSY NOTES

METASTASES

MICROSCOPE

Not men-
tioned

Moderate,
occasion-
ally

streaked
with
blood

Repeated
hsemop-
tysis

Not men-
tioned

Scant

Scant, mu-
coid,
occa-
sionally
bloody;
later

raspberry
jelly, no
tubercle
bacilli; a
little

later elas-
tic fibres

lobe of right lung; tubercU'
lar, possibly syphilitic nod'
ules in kidneys

Two tumors in right lower
lobe size of a hazel nut, one
of which ulcerates into the
bronchus

Entire right upper lobe
except at very top converted
into nodular medullary tu-
mor extending to enlarged
lymph nodes in anterior m&
diastinum. Compression of
upper cava, trachea, and left
bronchus

Bloody fluid in left pleura.
Solid tumor of left lower
lobe from hilus to upper part
of lobe. Tumor has invaded
wall of left main bronchus
and extends into its ramifi-
cations, completely obliter
ating the smaller bronchi
Lower part of left lower lobe
consists mainly of tumor
nodules

Large tumor occupying
greater portion of upper left
lobe. Numerous nodules of
various sizes throughout re-
mainder of left lung and
pleura. Right lung normal.
Effusion of yellow serum in
both pleurae and pericardium

Bloody serum in left
chest; clear serum in right.
Left pleura studded v/ith
tumor nodules; injection
of lymphatics with tumor.
Large masses of tumor
about the root of lung pene-
trating into the lung itself

Right lower lobe not ad-
herent ; no bronchial glands.
In the lower lobe surrounded
by a thin layer of lung tissue
a large tumor, grayish-white,
partially firm and hard, par-
tially soft; not sharply de-
fined, but merging into sur-
rounding lung tissue. All
other organs healthy

None

No other
metastases

Not given

Left auri
cle, pulmon-
ary veins,
right auricle,
mediastinal
and bron-
chial lymph
nodes

No metas-
tases

Bron-
chial and
mesenteric
lymph
nodes, both
suprarenals

None, not
even a single
gland

Microscopic
diagnosis
somewhat
uncertain.
Probably car-
cinoma of
scirrhus-like
structure

Alveolar
structure ;
isomorphous
epithelial
cells

Scirrhus

Alveolar
structure,
much necro-
sis. Alveoli
lined with
cylindrical,
sometimes
cuboidal epi-
thelium; also
large giant
cells

Probably of bron-
chial origin

Author suggests
possibility of alveolar
origin

Notice the very
slow and chronic pro-
cess of the disease,
lasting over two years
with but very slight
systemic disturbance

130

TABLE I

NO.

AUTHOR

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

BOUILIAND,

Journ. complimen-
taire du Dictionnaire
des Sciences medi-
cales, 1826, Vol. 26, p.
289

Observations sur le
Cancer des Poumons,
etc.

Pain in chest, harassing cough, fever.
Increasing weakness and emaciation.
Right lung normal. Absence of
breathing over left chest. Duratiott
of disease about 7 months

BOTJTGTJES,

Bull, de la Soc. Ana-
tom. de Paris, 1888,
657
Cancer primitif du Pou-
mon gauche

No previous serious illness. For 3
months pain in left chest, loss of
strength and appetite and much ema-
ciation. Occasionally bloody stools.
Some cough; no expectoration; never
bloody sputum. Tenderness and some
resistance in epigastrium. Flatness
over the whole of left lung. Almost
entire absence of vocal fremitus.
Heart displaced. Hardly any dyspnoea.
Some few infraclavicular glands. Clin-
ical diagnosis: tumor of lung secondary
to cancer of stomach. Death a few
days after admission with intense pain
and dyspnoea

Boyd,

Lancet, 1887, II, 60
Cancer of Bronchial

Glands and Lungs

No clinical history

Log. cit.

No clinical history

Bremker, Arthur,
Am. Jour. Med. Sci-
ences, Vol. 136, 1903,
No. 6, pp. 1020-29

Case of Probable Pri-
mary Cancer of the
Lung

Pain in left chest, cough. (Shortly
before beginning of disease had been
assured that heart and lungs were
sound.) Dulness, later flatness over
lower left lung. Heart displaced to
right. Later dyspnoea, bulging of left
chest. Bloody serum aspirated

Bristowe,

Lancet, 1860, 1. 496

Not

mentio

ned

Not mentioned

CARCINOMA

131

SPTTTUM

AUTOPST NOTES

METASTASES

MICROSCOPE

BEMABES

and large

polymor-

phous

pave-

ment

cells;

once a

nest of

concen-

tric epi-

thelial

cells as-

suring

the diag-

nosis

Occasion-

Left lung closely adher-

Bronchial

Not given

ally

ent; pleura much thickened

and medias-

bloody,

and shrunken; left pleural

tinal glands

mucoid,

cavity | smaller than right.

later

Nearly whole of left lung

putrid

transformed into scirrhus-
like tumor with broken-
down areas in its interior.
Left main bronchus com-
pletely obliterated by tumor

None

Left pleura thickened and
infiltrated with tumor, also
diaphragm. Tumor infil-
tration throughout whole of
left lung. Walls of bronchi
thickened. Pericardium in-
vaded by tumor. Heart,
stomach and all other organs
healthy

Right lung,
left pleura,
liver, medi-
astinal,
bronchial,
retroperi-
toneal
Ijonph
nodes, right
kidney

Not given

Cancer of right main
bronchus reaching to bifur-
cation. Large solid tumor
in right lung involving
pleura and pericardium

Bronchial
lymph nodes

Carcinoma

Not given

Cancer of root of left lung.

Upper

Not men-

Obstruction of left main

left lobe

tioned

bronchus by proliferating

tumor masses in its lumen

Not given

1500 c.c. bloody iSuid in

None

Cyst-adeno-

Possibly from bron-

left pleura. Tumor in left

carcinoma

chus. (I. A.)

lower lobe

Not given

Specimen exhibited to il-

Not men-

This is undoubted-

lustrate peculiar growth of

tioned

ly a case of primary

132

TABLE I

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

BuHD, E. Ltcett,
Transact. Path. See
London, 1891, p. 55

Primary Carcinoma of
Lung

Chiabi,'

Prag. Med. Wochen-
schr., 1883, p. 497

Zur Kenntniss der Bron-
chialgeschwulste

Not
giv-
en

Claisse,

Bulletin a Memoires
de la Soci6t6 Medi-
cale des Hop. de Paris,
1899, p. 46

Diagnostic precoce du
Cancer du Poumon
par I'etude histolo-
gique des Crachats

Coats,

Transact. London
Path. Soc, Vol. 34,
1888, p. 326

A Case of Multiple Can-
cerous Tumors, many
of them Cystic, in
Lungs, Brain, Bones,
etc. Primary Tumor
probably in the Lung

CoHN, Pattl^
.. Diss. Leipzig, 1903
Uber verhornenden

Not
stated

Admitted for right pleurisy; dis-
charged 3 weeks later much relieved.
Readmitted 16 days thereafter with
stitch in side, cedcema o2 face, s,rms and
chest; much dyspnoea; dilatation of
veins over shoulders and front of chest.
Slight dulness over limited area in
front on right chest. No adventitious
lung sounds; no heemoptysis. Death
about 6 weeks after admission

No clinical history except "marked
marasmus present"

Health had been perfect but began
to fail. Nothing could be found on
lungs. Expectorated 2 particles about
the size of a cherrypit from which
diagnosis was made many weeks before
sjrmptoms of tumor of lung appeared

Entire clinical picture dominated
by symptoms from nervous system —
vomiting, headache, strabismus,
choked disc. Normal temperature,
normal respiration. Nothing pointed
to disease of lungs. Tumors appeared
in both femurs, various ribs, and
around lumbar spine. Convulsions,
coma, death. Duration of disease
about 8 months

No clinical history

CARCINOMA

133

SPUTUM

AUTOPSY NOTES

METASTASES

MICHOSCOPE

BEMAHK3

cancer in lung, radiating

cancer of the lung

along bronchial tubes

with infiltrations
along the bronchial
ramifications

Not men-

Upper lobe of right lung

Medias-

Not men-

tioned

infiltrated with new growth.
Right bronchus occluded

tinal lymph
nodes form-
ing large
mass adher-
ent to peri-
cardium,
root of lung,
oesophagus,
and great
vessels

tioned

•

No details

Primary tumor in left

Right

Papillary

lower lobe starting from

lung, both

structure

hilus

pleurae,
bronchial
and supra-
clavicular
lymph
nodes, liver,
spleen, and
in cortex
and medulla
of both cere-
bral hemi-
spheres

covered with
cylindrical
epithelium.
No ciliated
epithelium.
Alveolar epi-
thelium and
bronchial
mucous
glands not
involved

No details

Autopsy confirmed clini-
cal diagnosis

No details

Sections of
the particles
expectorated
showed epi-
thelioma

None

In upper part of lower

Bronchial

Alveolar

Cystic adeno-car-

right lobe large ragged cav-

lymph

and cystic

cinoma, probable ori-

ity, the walls of which are

nodes.

structure

gin from bronchial

formed of grayish neoplasm.

bones, lungs,

with cylindri-

mucous glands

Solid tumor adherent to bi-

pancreas.

cal epithe-

furcation and bulging into

liver, peri-

lium_ at base

both main bronchi; at two

toneum, _

and irregular.

places tumors proliferate

retroperito-

cuboid, and

into right main bronchus

neal and
mesenteric
lymph
nodes, ver-
tebrae, fe-
murs, and
at least 22
cystic tu-
mors in
brain

polymor-
phous cells in
interior of
alveoli.
Much colloid
and mucoid
material in
alveoli and
cysts

No data

Cavity in left upper lobe

Ribs,

Typical

with necrotic sequestrum.

clavicle, fe-

cancroid

Tumor infiltration and nod-

mur, spleen,

with horny,

134

TABLE I

Plattenepithelial-
krebs der Lunge

Davy,

Lancet, 1882, II, 257

Degen,

.. Dis3. Ziirich, 1897

Uber einen Fall von

primarem Lungen-

carcinom

Delorme,
,. Diss. Jena, 1901
Uber primares Lun-
gencareinom

DiNKLEH,

Verhand. d. Path
Gesell., 1900, p. 59
Ein Fall von primarem
Lungencarcinom

Loc. CIT,

Discussion by Ponick

Loc. CIT.

Discussion by Langen-
hans

DOEMENT,

Zeitschr. f . Heilkunde,
1902, III

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

Cough; dulness and bronchial respi-
ration at left apex; pain in left side,
impaired respiratory motion. No
fremitus, feeble breathing ; interspaces
flattened; emaciation. Later swell-
ing of liver and ascites

No heredity; always healthy until
half year before admission when jaun-
dice and pain in abdomen. Physical
examination of lungs negative. Large,
nodulated liver. Clinical diagnosis
cancer of liver, possibly cancer of
stomach. At no time any symptoms
pointing to lungs; no cough; no pain

No heredity; no previous illness.
Cough, fever, scant expectoration, re-
traction of left chest from 1st to 4th
ribs; dilated veins; dulness. Dimin-
ished respiration but normal vocal
fremitus. Large bronchiectatic dila-
tation at left base. Later clinical
picture dominated by paralytic symp-
toms in left arm and right face.
Severe headaches and neuralgias.
Later secondary nodules in numerous
places — lymph nodes, ribs, sternum,
skull. Duration not quite one year

Diffuse bronchitis and broncho-
pneumonia

Healthy and strong. Sudden death
from haemoptysis. No other clinical
symptoms

Irritating laryngeal cough for some
weeks; sudden fever. Clinical diag-
nosis pneumonia. Death in 6 days

No clinical history. Diagnosis made
correctly during life

Cough, pain in side. Dyspnoea

CARCINOMA

135

AUTOPSY NOTES

METASTASES

MICROSCOPE

Abundant
mucous
expecto-
ration ;
no blood

None

Scant,
occasion-
ally
tinged
with
blood

No details

None

Bloody

No data

Purulent

ules around cavity. Wall
of afferent bronchus de-
stroyed by tumor but com
municates with cavity. Tu
bercular cicatrix in right
apex and at Bauhini's valve

Clear serum in both
pleurae. Left main bron
chus compressed by tumor
at the hilus penetrating into
lung and invading pleura

Small, primary infiltrat-
ing cancer of left lung with
miliary nodules along lym-
phatics of left pleura. Be-
sides the cancer an eruption
of miliary tubercles

Primary carcinoma of left
bronchus; right pulmonary
vein perforated by tumor

Both lungs uniformly dis
eased, gross aspect resem-
bling most a cheesy pneu-
monia

Degenerating carcinoma
of left main bronchus pene-
trating into a large branch
of the pulmonary artery

Hard carcinoma of left
main bronchus. Compres-
sion of left pulmonary ar-
tery. Hgemorrhagic infarc-
tion of left lung

Extensive diffuse infiltra-
tion of both lungs resem-
bling pneumonia

Carcinoma of inferior
right lobe extending into in-
ferior cava. Chronic tuber-
culosis of lung

liver, right
kidney, left
adrenal, ret-
roperitoneal
glands. No
metastases
in bronchial
glands

Bronchial
lymph nodes

Liver,
tracheal and
bronchial
lymph nodes

Pericardi-
um, pleura,
bones of
skull, both
suprarenals,
liver, vari-
ous long
bones, ster-
num, ribs,
lymph nodes

Stomach

No details

Bronchial
lymph
nodes

Diaphragm,
right lobe of
liver

pavement
epithelium

No details

Squamous
celled carci-
noma of
scirrhous
type

Cylindri-
cal celled car-
cinoma

Tumor is simply
called cancer

Carcinoma

No details

Cylindri-
cal celled car-
cinoma

Epithelioma
said to origi-
nate from
pulmonary
alveoli

136

TABLE I

NO.

AUTHOH

SEX

AGE

LUNG IN-
VOLVED

clinical symptoms

Log. cit.

Fever, dyspnoea, palpitation, pain in
right side, cedcEma of both legs. Bloody
effusion in right pleura

LOC. CIT.

No clinical history given

Log. err.

Not
stated

Headaches, pain in left chest, dysp-
noea; tenderness over right ribs; cyano-
sis, salivation, clouded vision; cough

Log. cit.

No clinical history

Log. cit.

Not
stated

No clinical history

Log. cit.

Severe headaches, disturbances of
vision and hearing; somnolency and
paralysis. Clinically diagnosed as
tumor or tuberculosis of brain

Log. cit.

Fever, cough, pain in right chest,
dyspnoea. Flatness over right pos-
terior base

Log. cit.

Severe cough ; flatness right apex
anteriorly, bronchial respiration and
rales

Log. git.

Cough, pain in left chest, paresis
left arm; fever, severe pain in back.
Dulness, diminished breathing in left
interscapiilar space. Bloody fluid in
pleura

DOHSCH,

Diss. Tiibingen, 1886
(quoted by Passler)
Ein Fall von primarem
Lungenkrebs

No clinical history

CARCINOMA

137

Mucoid
and

haemop-
tysis

Not stated

Scant

No details

Not stated

Abundant

Haemop-
tysis

Bloody

No details

AUTOPSY NOTES

Carcinoma of middle and
lower right lobes; carcinosis
of right lung

Carcinoma of bronchi and
right lung; also tuberculosis

METASTASES

Medias-
tinal lymph
nodes, liver,
and thyroid

Liver, bron-
chial lymph
nodes

Bronchial cancer of right
upper lobe ; stenosis of bron^
chus. Old apex tubercu-
losis

Carcinoma of right bron-
chus

Carcinoma of left inferior
lobe

Two medullary tumors in
right upper lobe, starting
from right main bronchus at
root of lung and extending
into bronchus and upper

Bronchial
lymph nodes
left kidney

Not stated

Tumor in main bronchus
of right lower lobe ulcerat-
ing into lumen and almost
completely obstructing it.
From bronchus tvunor pene^
trates into right lung

Carcinoma of right in-
ferior lobe; tuberculosis of
right lung

Carcinoma proliferating Bronchial
along bronchi of lower lobe lymph nodes

In left lower lobe, sur- 7 metas-
rounding main bronchus, tases in
cancerous mass radiating in- brain ; no
to surrounding lung tissue others

MICKOSCOPE

No details

B.ronchial ele-
ments found
normal and
origin of
tumor re-
ferred to
alveolar epi-
thelium

Carcinoma
originating
from bron-
chial epithe-
lium

Not stated

No details

Bronchial
and medias-
tinal lymph
nodes, peri-
cardium,
both pleurae

Bronchial
lymph nodes
perforating
into auricle

Cranium,
6th rib,
Uver, bron-
chial and
retroperito-
neal lymph
nodes, brain,
right kidney

Bronchial
lymph
nodes,
lungs, liver,
spleen, kid-

Cylindrical
cells of ade-
nomatous
structure
originating
from bron-
chial mucous
glands

Cylindrical
celled adeno-
matous can-
cer, originat-
ing probably
from bron-
chial mucous
glands

No details

Large poly-
morphous
epithelial cells
tending to
fatty degen-

138

TABLE I

Dbtsdalb,

Medical Press & Cir-
cular, Vol. LIII, N.S.,
London, 1892, p. 628

Case of Cancer of Left
Liing

Ebert

Virch. Arch., Vol. 49,

1870, p. 61
Zur Entwickelung des

Epithelioma der Pia

und der Lungen

Ebstein,

Deut. Med. Wochen-

schr., 1890, p. 921
Zur Lehre vom Krebs

der Bronchien und

der Lunge

Log. cit.

Ehrich,

.. Diss. Marburg, 1891

Uber das primare

Bronchial- und Lun-

gencarcinom

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Sick for 3 months with bronchitis;
coughed up much pus. Dulness over
left base, diminished fremitus and
moist rales. Dulness gradually ex-
tends; emaciation. At one time
cough less troublesome and felt better.
More breathing heard over left lung.
Later increasing diilness, symptoms of
cavity, diarrhoea and death. During
life diagnosis was doubtful and malig-
nancy suspected only towards end.
Duration about 10 months

Clinical history refers mainly to
brain symptoms. Repeated examina-
tions of chest negative. A few days
before death, fever and cough. Dysp-
noea and some cyanosis. Examination
showed extensive dulness over left
lower lobe and bronchial breathing;
some friction

Family history of cancer. Clinical
nosis myocarditis, dilatation of
heart, emphysema, bronchitis, effu-
sion in right pleural cavity, diabetes.
Disease extended over a number of
years with occasional improvement.
For several years no signs on lungs
except some rales. Sudden death
from heart failure

Pain in left chest extending later to
back and right chest. No cough, in-
creasing emaciation, slight tempera-
ture; dyspnoea; dulness at left base
which remains stationary. Ribs un-
even and tender; slight area of dulness
on right side. Exploratory puncture
negative. Tenderness of liver with
enlargement of left lobe. Two days
before death tumor appeared on 6th
rib right side. 3 days before death
stupor and paresis of left upper eyelid.
Hemoglobin 62; reds 3,492,000; whites
32,000

For some months pain in both sides
of chest and between scapulae, later
paralysis of both legs. Very slight
cough. Clinical picture dominated by
typical symptoms of transverse mye-
litis. Nothing characteristic in lungs.
Fever up to 104

CARCINOMA

139

SPUTUM

AUTOPSY NOTES

METASTASES

MICHOSCOPE

REMARKS

cava. Compression of pul-

ney, frontal

eration

monary arteries

bone, and
dura mater

Mostly pro-

Pleura firmly adherent.

Not men-

Probably bronchial

fuse, at

Left lung contains numerous

tioned

carcinoma from hilus

times of-

abscesses. Large cavity at

fensive,

apex containing pus; larger

some-

cavity at base containing

times

blood, pus and debris. Rest

much

of lung infiltrated with can-

pus; occa-

cerous growth radiating

sionally

from posterior mediastinum

bloody.

Several

hsemop-

tyses. No

tubercle

bacilli

None

Left lung completely infil-
trated with whitish medul-
lary mass; small nodules of
similar character in right
lung

None

Alveolar
structure
lined with
ciliated epi-
thelium

None

Main tumor in peribron-

Peritracheal

Cylindrical

chial tissue of right lower

and retro-

celled carci-

lobe; strands of tumor in

peritoneal

noma

both lungs along peribron-

lymph nodes

chial and perivesicular lym-

phatics

None

Carcinoma from left main

Regionary

Cylindrical

bronchus at root, proliferat-

lymph

celled carci-

ing into left lower lobe

nodes,
pleura, liver,
gall-bladder,
kidneys,
both supra-
renals,
brain, pan-
creas, peri-
toneum, and
various
bones

noma

Scant, mu-

Carcinoma in bronchus

Bronchial,

_No details;

copuru-

and tissue of left upper lobe.

cervical and

origin from

lent, no

Continuous propagation to

retroperito-

bronchial mu-

tubercle

pleura and 6th to 8th dorsal

neal lymph

cous glands

bacilli, no

vertebrse with compression

nodes, liver.

elastic

myelitis. Diffuse carcino-

spleen, kid-

fibres

sis of pleura and lung

neys, right
suprarenal,
thyroid, hy-

140

TABLE I

NO.

AUTHOR

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Log. git.

No heredity. Always well until
short time before admission when
some bronchitis and later haemoptysis.
No dyspnoea; not much pain. Dul-
ness, diminished respiration and voice
over right upper lobe which dis-
appeared later. Marked emaciation.
Bloody effusion in right chest; large
lymph node in right a,xilla

Log. cit.

Clinical diagnosis; tumor of anterior
mediastinum

Elisbebg,

Diss. KSnigsberg,

Uber disseminirte^
Miliarkarzinose;
besonders der Lungen
ohne makroscopisch
erkennbaren prima-
ren Tumor

No heredity. Spasmodic dry cough
worse on lying down; increasing
dyspnoea and weakness; some cyanosis;
no emaciation; no fever. Right chest
somewhat sunken, drags in respira-
tion. Dulness over right chest with
loss of breathing and voice. Left
chest normal. Blood and urine nor-
mal. Duration of disease 4 to 6
months

Ennet,

Diss. Greifswald,

1902 (after Angel-

hoff)
Ein Fall von primarem

Krebs der rechten

und Tuberkulose der

linken Lunge

Cough and dyspnoea dating from
fall; later flatness over right chest,
dulness above. On aspiration turbid
bloody fluid containing clumps of large
epithelial cells. Increasing dyspnoea.
Duration about year and a half. Clin-
ical diagnosis: pulmonary tuberculosis

Ernst,

Ziegiers Beitrage,
Vol. XX, 1896, p. 155

Abrupt onset of disease with obscure
clinical symptoms suggesting menin-
gitis or cerebral haemorrhage ; at same
time cough, dulness at right apex.
Patient died shortly after he began to
complain

CARCINOMA

141

SPTTTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

EEMARKS

pophysis,

dura and

1st and 7th

left ribs

Mostly

Carcinoma from right

Pericar-

Alveolar

Supposed origin

bloody ;

main bronchus involving

dium, chest

structure

from bronchial mu-

at one

pleura and chest wall. Ribs

wall, ribs,

with large

cous glands

time ex-

perforated by cancer. In

pleura.

polymor-

pectora-

lower lobe of right lung a

bronchial

phous cells

tion of

large cavity filled with nec-

nodes and

villous

rotic tissue and communi-

diaphragm

and

cating with right bronchus,

bloody

which is nearly completely

masses

obstructed by large prolifer-

which

ating tumor

con-

tained

cancerous

material

No details

Tumor lower part of tra-

Bronchial

Same as

chea and right main bron-

and medias-

above

chus and its branches. Com-

tinal lymph

plete atelectasis of right

nodes, left

tung. Hard, firm, white

lung, liver,

tumor at the root matting

heart

together pleura, trachea, _

bronchus, large vessels, peri-

cardium, compressing upper

part pulmonary artery. Tu-

mor infiltration left lung

Scant, mu-

Effusion in right chest.

Bronchial

Transition

coid, oc-

Miliary carcinomatous nod-

lymph

from cylindri-

casionally

ules over both lungs and

nodes, peri-

cal and cu-

bloody

pleurae. Compression of

toneum and

boid to small

right bronchus; extensive

mucous

polyhedral

carcinomatous infiltration

membrane

cells

through the lymph channels.

of bladder

Papillary and nodular tu-

mor masses in bronchial mu-

cous membrane

Often

_ Carcinoma of whole of

No details

Typical cy-

bloody.

right lung and right pleura;

lindrical epi-

contains

ulcerating tuberculosis of

thelial cells

tubercle

left upper lobe

bacilli

Mucopuru-

Carcinoma of bronchus of

Lsmiph

Capillary

lent

right upper lobe extending

nodes, dura.

structure _

to main bronchus

brain, cere-
bellum, left
suprarenal

covered with
epithelium
resembling
epidermis
with prickle
cells and ker-
ato-hyaline;
also spindle
shaped giant

cells

142

TABLE I

FiNLET & PaBKEH,

Medical Chirur.
Trans., London,
1877, Vol. LX, 313-
324
Primary Cylindrical-
celled Epithelioma of
Lung

FOA,

Giorn. della R. Acad.
di Med. di Torino,
Vol.42, 1894, p. Ill
Un Caso Cancro primi-
tive del Pulmone

Frankel, a.

Spezielle Pathologie
u. Therapie der Lun-
genkrankheiten, 1904

86 Loc. ciT.

Fbiedlander,

Fortschr. d. Med.,

1885, 1, p. 307 (after

Passler)
Cancroid in einer Lun-

gencaverne

Froelich,
.. Diss. Berlin, 1899
Uber das primare
Lungencarcinom

Not St

Not
stated

LUNG IN-
VOLVED

ated

CLLNICAL SYMPTOMS

Pain in left chest, cyanosis, dyspncea,
clubbed fingers, cough, diminished
respiratory movement of left chest.
Flatness, feeble breathing, diminished
fremitus. Aspiration negative. Later
enlargement of 5upracla\'icular glands

No cUnical history

In perfect health until taken with
chill and fever up to 104; dyspnoea
flatness over whole of right lower lobe,
loss of fremitus, diminished respira-
tion. Pneumonia with gangrene of
lung was diagnosed. Death before
2nd week of disease •

For 2 years pain, cough, dulness
over left lower lobe, feeble bronchial
respiration, abundant rales. Dulness
gradually extends over greater part
of left chest. Puncture negative.
Roentgen raj^ showed complete in-
duration of entire left lung. Later
flatness gradually diminishes until
percussion note becomes normal every-
where except one small area. Later
again becomes tympanitic and finally
absolutely flat until death. Inguinal
IjTuph node had been removed and
found carcinomatous, which corrobo-
rated clinical diagnosis of carcinoma of
left lung. Duration about 2| years

No clinical history

No heredity. Cough, pain in left
chest, debility, anorexia; irregular flat-
ness over left chest; diminished voice
and respiration. Hsemorrhagic_ effu-
sion in left pleura; later retraction of
left chest, cyanosis, intense dyspnoea;
later still amphoric breathing in lefti

CARCINOMA

143

SPUTUM

AUTOPSY NOTES METASTASES

MICROSCOPE

EEMAEK8

Pink

Large, soft, pulpy tumor Mediastinal

Alveolar

in upper left lung and supra-

arrangernent

clavicular

with typical

lymph

cylindrical

nodes,

cells

pleura, both

lungs, liver,

right kidney

No details

Author calls tumor a

Liver,

Partly cy-

broncho-pulmonary cancer

kidneys

lindrical,
partly polyg-
onal pave-
ment epi-
thelium.
Author at-
tributes ori-
gin cylindri-
cal epithe-
lium to
bronchi;
pavement to
alveoli

Mucopu-

Right lower lobe bronchi-

LjTnph

Cylindrical

rulent,

ectatic ca\dties filled with

nodes at

celled carci-

copious;

puriform secretion. Prolif-

hilus

noma

later

eration into main bronchus

dirty

of lower lobe of medullary

brown

tumor almost completely

and foetid

obstructing lumen and per-
forating through wall

Occasion-

Occlusion of left main

Inguinal

Cylindrical

ally

bronchus with nodular med-

lymph

celled carci-

bloody

ullary tumor size of a man's
fist at hilus, extending into
lung tissue

nodes; gen-
eral carcino-
sis of entire
left lung

noma

No details

A white medullary mass
from bronchus of left upper
lobe. Only in this bronchus
and in a tubercular ca\'ity
in left lung has cancer de-
veloped

None

Horny pave-
ment epithe-
lium with
typical can-
croid pearls

Scant, occa-

Abundant bloody exudate

Both lungs,

Pavement

sionally-

in left chest. Pleura much

pleura, peri-

epithelium

bloody;

thickened and adherent on

cardium.

later

all sides to extensive tumor

bronchial.

raspberry

masses, so that exudate is

mediastinal.

jelly and

completely encapsulated.

cervical

contains

Posterior portion of upper

lymph

144

TABLE I

NO.

AUTHOR

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

chest. Enlargement of cer%'ical lymph
nodes; nodular enlargement of liver;
paralysis of left recurrent; death.
Duration of illness about 9 months

Log. err.

No heredity. Pain in left side,
cough. Increasing dulness left chest,
bronchial breathing and rales. Re-
traction of left chest with cessation of
respiratory movements. Increasing
cachexia. Clinical diagnosis pneumo-
nia and marasmus

FrrcHS,

Diss. Miinchen
Beitrage zurKennt-
niss der primaren
Geschwiilstbildungen
in der Lunge

Both

No clinical history

Log. git.

No clinical data except that the
diagnosis was cerebral atrophy

Log. err.

Both

No clinical history except marked
emaciation

Log. cit.

Both

No clinical history except during
stay in hospital intestinal obstruction
was suspected. Great emaciation

FUCHS,

Diss. Leipzig, 1890
Beitrage zur Casuistik
des primaren Lun-
gencarcinoms (after
Passler)

No cUnical history

Log. cit.

No clinical history

Geipel,

Centralbl. f. Allgem.
Pathol, u. path. Anat.
X, 1899, p. 848

Patient suffered for some time from
severe pulmonary trouble. No other
clinical history given

CARCINOMA

145

AtTTOPST NOTES

At first
none,
later
scant, no
tubercle
bacilli

and lower lobes contains
masses of tumor in which
are found numerous cavities
filled with pus

Encapsulated bloody exu

date in left pleura. Upper
left lobe a shell of lung tissue
infiltrated with tumor and
surrounding cavities filled
with putrid and degenerat-
ing tumor material

Primary cylindrical celled
carcinoma of both lungs ap
pearing in numerous nod
ules, many of them conflu-
ent. Fibrinous effusion in
right chest

Medullary infiltration of
right lung with cavity in up-
per lobe. Foci of red and
yellow softening in cortex of
left anterior lobe of brain

Primary cancer with nod-
ules in both lungs in great
numbers of all si^es.
Chronic interstitial pneu-
monia

Medullary nodules in left
upper lobe. Bronchial mu-
cous membrane bulged by
nodules. Large cavity in
right middle lobe filled with
pedunculated soft, reddish-
brown material. Hsemor-
rhagic effusion in pericar-
dium with retraction of left
lung

Carcinomatous tumor size
of an apple in right lower
lobe; softening in interior

METASTASES MICROSCOPE

Subpleural tumor size of
an apple in right upper lobe.
Necrotic cavity in interior.
Origin from bronchial wall

Carcinoma of left main
bronchus penetrating into
left auricle and also into
aorta, but not to the intima

nodes, oeso-
phagus,
liver, endo-
cardium of
right ventri-
cle, bladder

Bronchial
lymph nodes

No details

Numerous
in dura

None

Pericardium
and liver

None

Right lower
lobe, region-
ary lymph
nodes, liver

Not men-
tioned

Squamous
epithelium

Ciliated
cylindrical
celled epithe-
lium

No details

Pavement
epithelium

Cylindrical
celled carci-

Alveolar
structure, cy-
lindrical cells,
here and
there ap-
proaching
pavement
epithelium

146

TABLE I

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

100

GOLDSCHMIDT,

Corresp.-blatt f.
Schweizer Aerzte,
1886, XVI, p. 67-69
Medullar Carcinom der
linken Lunge

GOUGEROT,

Bull, de la Sec. Ana-
torn, de Paris, 1905,
p. 294
Cancer primitif du Pou-
mon (Epithelioma
pavimenteux bron-
cho-pulmonaire) a
Globes epidermiques

Geun-wald,

Milnch. med. Wo-

chenschrift, 1889, No.

32-33
Fall von primarem

Pflasterepithelkrebs

der Lunge

Hall & Tribe,
Lancet, 1905, 1

Carcinoma of Bronchus
and Liver in a Youth
of 17 with Glycosuria

101

BLi.MPELN,

St. Petersburg Med,
Wochenschrift, 1887,
No. 17
Fall von primarem
Lungen-Pleura Car-

Progressive emaciation, dyspnoea,
pain, dilated superficial veins. Flat-
ness, absence of voice and breathing
over greater part of left chest. No
fever; no cough. 700 c.c. clear bloody
serum aspirated from left chest

No heredity. Pulmonary tubercu-
losis of old standing. After grippe,
dyspnoea with cough and f ever._ Later
polyuria and polydipsia. Rapid ema-
ciation; some pain. Urine free from
albumin or sugar, though over 8000 c.c.
voided daily. Later painful points on
vertebrae; pains along right arm.
Clinical diagnosis tuberculosis

Pain in chest. Abnormal sensations
in throat. Dyspnoea, paralysis of left
recurrent laryngeal. At that time
heart and lungs found normal. Later
dulness over left upper chest; absence
of breathing. Physical signs vary.
Clinical diagnosis tumor of posterior
mediastinum compressing heart and
lungs and left recurrent nerve. Aspira-
tion practically negative. Some cough.
Duration about one year

For 3 months cough, dyspnoea, ema-
ciation; thereafter intense itching,
enormous appetite, polyuria; some
cyanosis; oedoema of face, neck, and
feet; purpuric spots partly suppurat-
ing over the legs. Swellings filled with
fluid over scapula, back, anus, and left
arm. Bronchial breathing with some
rales over left apex. Enlarged nodular
liver; some fever. Urine contains
much sugar; some diacetic acid. Sud-
den collapse and death. Duration
about 3 months. Clinical diagnosis
pyaemia with suspicion of tuberculosis

No heredity; disease started with
slight fever and enlarged spleen;
treated as malaria and improved.
Later pain in left chest and dyspnoea;
pleuritic effusion which was absorbed
without tapping. Later slight cough
followed by emaciation and general
cachexia without subjective symp-
toms. No pain, good breathing, good
appetite. Physical signs suggested
merely incomplete absorption of pleu-
ritic effusion. Duration of disease
probably not more than one year

CARCINOMA

147

AUTOPSY NOTES

METASTASES

MICEOSCOPE

None

Mucopuru-
lent, often
bloody,
contains
tubercle
bacilli

Scant, occa-
sionally
bloody

Mucopu-
rulent,
bloody,
no tuber-
cle bacilli

Scant, gela-
tinous,
occasion-
ally
bloody
or pink.
Micro-
scopic ex-
amina-
tion
showed
numer-
ous epi-
thelial
cells sug-
gesting
tumor,
from
which
alone the

Entire left lung except up-
per portion of upper lobe
converted into medullary
cancer

Neoplasm, involving en-
tire right upper lobe with
cavity. Right main bron-
chus at root obstructed by
tumor up to bifurcation.
Compression of tracheal and
cervical plexus

Solid tumor size of fist in
central portion left lower
lobe. No cavities. All
bronchi compressed; cesoph
agus matted to trachea by
tumor

Irregular tumor, lower
lobe of left lung, starting
from hilus, spreading along
bronchus into lung; main
bronchus almost occluded.
Pancreas normal

None Not men-

tioned

In lower lobe a tumor the
size of a fist, broken down in
centre, but surrounded by
normal lung tissue

Peritra-
cheal, peri-
bronchial
lymph
nodes; left
kidney

Bronchial
and medias-
tinal lymph
nodes; left
ventricle
and 2 nod-
ules in liver

Upper lobe,
liver, retro-
peritoneal
and cervical
lymph
nodes, parts
of skull

None

Typical pave-
ment epithe-
lium with
horny pearls.
Origin from
bronchus

Pavement
epithelium

Columnar
celled carci-
noma. Ori-
gin from
bronchus

148

TABLE I

102

103

104

105

106

Handpord,

London Path. Trans.
Vol. 39, p. 48

Two Cases of Medias-
tinal Cancer

Log. cit.

Handford,

London Path. Trans.,

Vol. 40, p. 40
Primary Carcinoma of

Left Bronchus

Handford,

London Path. Trans.,

Vol. 41, p. 37
Carcinoma of Root of

Lung (after Passler)

Harbitz, Francis,
Norsk Mag. f. Lae-
gevidenskaben., Aug.,
1903, p. 715

Primarer Krebs in einer
Lunge mit bronchiec-
tatischen Cavemen ;
Metastasen im Ge-
hirn und in dem

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Cough and failing health 6 months
before admission. Loss of flesh, pain
between shoulders and at sternum.
Difficulty in swallowing anything but
fluids. On admission: difficulty in
swallowing most urgent symptom and
steadily increasing. Profuse haemop-
tysis and death. Duration of disease
about 7 months

Cough more or less for 20 years.
5 years ago profuse haemorrhage. 2
years ago loss of voice for 2 months;
unable to work for 18 months; much
loss of flesh; musctilar pains. Hectic
temperature, occasionally up to 104f .
Dulness over nearly all of right lung,
especially over lower lobe. Later
pleuritic effusion in right chest; aspira-
tion 30 ounces of turbid serum. Later
swellings in upper humerus, right
deltoid, left upper arm and left thigh.
Smaller nodules in scalp. Sudden
death from haemoptysis

Well until 5 years before admission;
then had fall and hurt chest. Cough
and loss of flesh since. Deficient ex-
pansion of left chest; dull percussion
especially in upper part. Feeble, dis-
tant tubular breathing, finally com-
plete absence of breathing sounds.
Paroxysms of dyspnoea; hoarseness.
Clinical diagnosis: new growth or
aneurysm pressing on left main bron-
chus. Death from profuse haemop-
tysis. Duration of disease about 6
months

None given

Tubercular family history. Had
syphilis. At 34 years had influenza
and coughed ever since. Sudden acute
pains in both sides of chest ; bedridden
since. Sweating; intense thirst. On
admission dulness over left lung; rales
over both lungs. To the left of ver-
tebral column on level with 10th rib a
long, pseudo-fluctuating mass. Fusi-

CARCINOMA

149

AUTOPSY NOTES

METASTASES

MICROSCOPE

Large tumor in left lower
lobe covered by thickened,
infiltrated pleura. Tumor
proliferates into mediasti-
num, where there is large
cavity filled with bloody
fluid communicating with
main bronchus and left
auricle

Carcinoma of root of right
lung spreading along bron-
chial ramifications and large
vessels. In lung tumor
masses in parts softened
and forming cancerous cav-
ities from which haemorrhage
originated

Hypostatic pneumonia
right lung. New growth had
spread along interior of left
bronchus, completely filling
its lumen, and reaching up
into trachea above bifurca-
tion. Numerous small tU'
mor nodules over left vis
ceral pleura

Carcinoma of root of left
lung, obliterating lower sec-
ondary bronchus, and pro-
liferating along bronchial
ramifications

Mucopu- Small tumor in rectus ab-

rulent, dominis, also in musculature
several of back near spinal column,
times Upper surface of right lung
pure studded with nodules often

blood, no umbilicated. On section
tubercle lung shows many grayish
bacilli red tumor nodules, both dis
Crete and confluent. Much

Medias-
tinum, cer-
vical lymph
nodes, liver,
left auricle,
pericardium

Bronchial
lymph
nodes, vari-
ous muscles
of trunk,
various
bones, skin,
kidneys

Bronchial
and medias-
tinal lymph
nodes, liver

Left pleura,
liver

Right lung
brain, cere-
bellum, ribs
sternum,
liver, kid-
neys, mus-
cles of back
and abdo-

Typical al-
veolar struc-
ture of scir-
rhous carci-
noma

Alveolar
structure,
abundant
stroma, epi-
thelial cells

Carcinoma
of scirrhous
type, origi-
nating from
mucous mem-
brane of bron
chua

Alveolar
structure,
well devel-
oped stroma
and abundant
epithelial
cells

Alveolar
structure ;
alveoli lined
with high cy-
lindrical cells.
Small bron-
chi contain
these cells in
active prolif-

150

TABLE I

107

108

109

110

111

112

113

Knochensystem

Loc. CIT.
p. 729

Loc. CIT.

(postscript)

Haebitz,

Quoted from Zeit-
schr. f. Krebsforsch.
I, 1904, p. 154

Hahkis,

St. Bartholomew's
Hosp. Reports, Vol.
28, 1892, p. 73

Intrathoracic Growths

Haktmann,
.. Diss. Kiel, 1896
tJber Lungenkrebs vom
Bronchus ausgehend

Hauff,

Schmidt's Jahr-
biicher. Vol. 182,
88

Ein Fall von Mark-
schwamm der Lunge
und des Herzens

Hatjte-Cceur,

Progres Med., 1886,
2nd series. III, 460-
462

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

form enlargement of 9th rib in left
axilla. Puncture of tumor at 10th
rib reveals brown colloid material
containing round or oval cells with
fatty degeneration. No fever while
in hospital. Died from marasmus 9
days after admission

Sick for a long time. Symptoms of
chronic cedoema of lung with short per-
cussion note. Ronchi over both lungs.
Slight cough

Sharp pain in left chest and right
arm. Later dyspncsa, dulness over
base of left lung, fremitus in left hy-
pochondrium. On puncture sanguin-
olent serum containing lymphocytes
and endothelium

No clinical history given in excerpt

Cough, dyspnoea, night sweats. Fluid
in right chest. Clinical signs those
of chronic phthisis, especially at right
apex. Duration 11 months

Cough for years; after a cold in-
creasing cough, dyspnoea and ema-
ciation. Dulness with diminished
bronchial breathing over left base
gradually extending over whole of left
chest. Aspiration 1500 c.c. serous
fluid containing fatty epithelial cells.
Clinical diagnosis: malignant neo-
plasm of pleura

Dyspnoea, pain; left apex dulnesa
and bronchial breathing. Insomnia.
Sudden death after 3 weeks

_ Oppression, pain; signs of fluid in
right chest. Swelling of right chest
and dilated veins. Flatness with faint
and distant breathing. Within 6
weeks 4 tappings of chest removing
large quantities of chocolate-colored
fluid containing cancer cells

CARCINOMA

151

AUTOPSY NOTES

METASTASES

MICROSCOPE

None

caseous degeneration. Left
lung adherent to thoracic
wall and smaller than right.
Nodules in lung tissue; cav-
ities in lower lobe

In main bronchus of right
lung circular thickening of
mucous membrane which
protrudes into lumen. In
substance of right lung large
and small lumps and infil-
trations of grayish color

Mucoid, no Adeno-carcinoma with
tubercle pronounced mucoid and col-
bacilli loid degeneration

Not men-
tioned

Profuse

Mucoid,
never
bloody

No details

Bronchiectatic cavities
with gelatinous tumor
masses in lungs, also bron-
cho-pneumonic foci with
cheesy and mucoid degener-
ation

Large portion of lower right
lobe occupied by neoplasm
which is very soft. Old tu-
bercular disease of both
apices

Carcinoma of left main
bronchus with destruction
of its walls. Irregular tu-
DQor nodules at hilus invad-
ing lung along bronchial
ramifications. Suppurative
pneumonia of entire left
lung. Compression of tra-
chea

Bloody fluid in both
pleurae, which are studded
with tumor nodules. Large
medullary tumor at left
apex ramifying in all direc'
tions. Right lung healthy

Right lung studded with
irregular cancer growths,
especially in lower part.
Pleura much thickened, can-
cerous mass in lower portion
of left lung compressing a
branch of the pulmonary
artery

Bronchial
and retro-
peritoneal
lymph
nodes,
pleura and
peritoneum

Pleura

Pleura,
bones, brain

Not men-
tioned

Bronchial
and medias-
tinal lymph
nodes and
liver

Pleura, peri-
cardium, in-
terventricu-
lar septum
of heart,
diaphragm,
liver and
left kidney

No details

eration. Mu-
coid degener-
ation

Polymor-
phous epithe-
lial cells un-
dergoing col-
loid degener-
ation

Adeno-car-
cinoma

Medullary
carcinoma

No details

Direct origin from
bronchial mucous
membrane could not
be established. Au-
thor thinks it prob-
able that tumor was
primary in lung

Only called

"Mark-

schwamm"

No details

152

TABLE I

NO.

ATJTHOH

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

114

HiLLENBERG,

Diss. Kiel, 1893
Ein Fall von primarem
Lungenkrebs

After influenza, pain in chest, cough.
Flatness with diminished respiration
over left apex extending downward.
Some dulness over right apex; later
symptoms of cavity in left apex.
Some tenderness over thoracic ver-
tebrse. Clinical diagnosis tuberculosis.
Duration about one year

115

HiNTERSTOISSER,

Wiener klin. Woch.,
1889, II, p. 374
Ein Fall von Karzinom
der grossen Luftwege,
etc.

Always well. Contusion of chest
from fall from horse. Shortly there-
after cough, difficult breathing, hoarse-
ness. Later enlargement of various
groups of lymph nodes. Dulness over
upper portion of sternum and left chest
merging into heart dulness. Paralysis
of left vocal cord. Painful, hard
swelling tip of right 4th finger. Finger
is amputated. Increasing dyspnoea
and exhaustion. Duration about one
year

116

HiTZ,

Diss. Zurich, 1887
Ein Beitrag zur Casuis-
tik des primaren
Lungencarcinoms

No heredity. Syphilis admitted.
Fever, cough, emaciation. Gradually
increasing symptoms of obstruction of
right main bronchus but no other evi-
dence of pulmonary disease. An at-
tack of pneumonia was followed for a
time by remarkable improvement of
all symptoms. Later increasing dysp-
noea, dysphagia, pain in right and left
chest, cough, oedoema. Death from ex-
haustion. Duration about one year

117

HOPMANN,

Diss. Zurich, 1893
(after Passler)
tjber malig. Lungen-
geschwiilste

Dyspnoea; intense pain in chest

118

Log. cit.

Intense dyspnoea

119

Horn, Oscar,

Virch. Arch., Vol. 189,

1907, p. 414
Ein Fall von primarem

Adeno-carcinom der

Lunge mit Cylinder-

epithel.

About 4 years before death dyspnceai
pain in chest, cough and expectoration.
Tympanitic note on left chest to 3rd
rib; increasing dulness below with
rales; diminished voice and breathing.
Profuse haemoptysis, increasing dysp-
noea, cyanosis. Sudden death

CARCINOMA

153

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

EEMAKKS

No tubercle

Large, degenerating car-

Right lung

Typical cylin-

bacilli

cinoma of left upper lobe.
Cancerous and pneumonic
infiltration of left lower lobe

and spleen

drical celled
carcinoma.
Author be-
lieves origin
to be from
bronchial
surface epi-
thelium

Mucoid,

Carcinoma of trachea and

Finger-tip,

Typical

Diagnosis made

often

bronchi

bronchial.

carcinoma

during- life from spu-

bloody.

mediastinal.

tum

Contains

cervical.

numerous

left supra-

epithelial

clavicular,

cells, sin-

right axil-

gle and

lary and

adherent

lumbar

in groups

lymph nodes

Mucoid,

Right main bronchus al-

Regionary

Alveolar

often

most completely obstructed

lymph nodes

structure

bloody,

by tumor proliferating into

with nests of

no tuber-

trachea. Posterior f of

large poly-

cle bacilli

upper lobe infiltrated with

morphous

or tumor

hard, firm, tumor; numer-

epithelial

elements

ous bronchiectatic cavities.

cells

ever

Enormous dilatation of left

found

lung

None

Large medullary tumor of

Not men-

entire left lung. Left main

tioned

bronchus obstructed and

compressed. Tumor perfo-

rates pulmonary vein and

left auricle. Aorta com-

pressed. Tumor prolifer-

ates into body of some of the

vertebrae

Not men-

Medullary tumor of right

Regionary

Not men-

tioned

main bronchus following
its ramifications to finest
branches. Proliferates up-
wards beyond bifurcation
and into left bronchus

lymph
nodes, both
pleurae and
left lung

tioned

Haemopty-

Left main bronchus com-

A few

Glandular

Origin probably

sis, choc-

pletely closed by tumor; left

glands at

structure;

from bronchial mu-

olate-col-

lung collapsed. Bronchi-

hilus; no

typical cylin-

cous membrane

ored and

ectatic cavities. Out of a

other metas-

drical celled

foetid

smaller cavity in the upper

tases

epithelium

sputum,

lobe a tumor mass grows

with basal

no tuber-

from a broad pedicle and

membrane.

cle bacilli

proliferates into one of the
larger upper bronchi, filling
it and budding into a num-
ber of smaller bronchi

cuticula and
cilia

154

TABLE I

120

HOYLE,

Jour. Anat. and
Physiol., XVIII, 509

Not

LUNG IN-
VOLVED

stated

121

122

123

124

Hughes, H. Marshall,
Guy's Hospital Re
ports,VI, 1841, p. 330

Cases of Malignant Dis
ease of the Lung

Hellt,

Zeitschr.f.Heilk.Vol.

28,1907. Path. Anat

p. 105
Ein seltener primarer

Lungentumor

Heremann,

Deut. Arch. f. klin.

Med.,Vol.63, 1899, p.

583
Zur Symptom, u. Diag.

des prim. Lungen-

krebses

Log. cit.

Both

CLINICAL SYMPTOMS

Fever; pain in right side of back.
No definite signs on lungs. Death
from profuse hsemoptysis

No heredity. Always healthy until
two years ago when caught cold; since
then occasional attacks of haemoptysis.
Cough, dyspnoea. Retraction of right
chest below clavicle; flatness, in-
creased fremitus, tubular breathing.
Dilated and tortuous veins of lower
abdomen and right chest. (Edoema of
legs. Enlarged lymph node in right
axilla and below right clavicle. Dura-
tion about 2§ years

111 for one year. Physical signs
seem to point to tuberculosis. Died
before full examination could be made
at hospital

Jaundice, oedoema of legs," enlarged
right supraclavicular glands. Dysp-
noea; no fever. Dulness and dimin-
ished voice and breathing over right
apex. Lungs otherwise normal. En-
larged nodulated Uver. Ascites

Cough, increasing dyspnoea, loss of
weight. CEdoema of eyelids; cyanosis;
no fever. Flatness and absence of
voice and breathing sounds over whole
of right chest. 1500 c.c. sero-purulent
fluid aspirated without diminishing
dulness; 2 days later 3000 c.c. with
the same result. Repeated aspira-
tions large quantities hsemorrhagic
serum. Swelling of right cervical
glands. Duration of disease a year
and half

CARCINOMA

155

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMABKS

No details

In upper lobe of left lung

Cavity in

Epithelioma

irregular cavity surrounded

liver; nod-

with typical

by tumor

ules with
soft centres
in left kid-
ney, iliac
fossa, 3rd
dorsal ver-
tebra and
5th rib

nests

Bloody

Entire upper lobe of right

Lower lobe,

No details

Diagnosis made

lung converted into medul-

Uver, both

during life on general

lary tumor with strands ex-

kidneys,

considerations

tending to middle lobe, with

right supra-

proliferation into right pul-

renal

monary artery

No details

Both lungs contained nu-

None. Not

Alveolar

Evidently malig-

merous nodules up to size

a single

structure of

nant and therefore

of walnut and frequently

lymph node

the adenoma-

classed under carci-

confluent. Boundary be-

enlarged or

tous type;

noma although struc-

tween tumor and lung not

any sign of

high cylindri-

ture is that of pure

sharply defined. It was im-

tumor

cal, non-cili-

adenoma

possible at autopsy to de-

throughout

ated epithe-

termine whether it was tu-

the body

lium with oc-

mor or some inflammatory

casional gob-

process

let cells.
Alveoli filled
with coagu-
lated mucoid
material

Jelly-like

Tumor at root of right

Bronchial

Tjrpical car-

and

lung surrounding bronchi ;

lymph

cinomatous

bloody,

one large bronchus obstruct-

nodes, both

structure

showing

ed by medullary tumor.

lungs, liver

under mi-

Foetid bronchitis, cirrhosis of

croscope

[iver, hypertrophic and fatty

plates of

tieart, interstitial nephritis

epithelial

cells from

which di-

agnosis is

made dur-

ing life

Bloody

Hard, whitish-yellow tu-

Not men-

expecto-

mor size of a hen's egg in

tioned

ration
2 days
before

region of right hilua

death

156

TABLE I

126

Loc. CIT.

LOC. CIT.

127

128

129

130

Loc. CIT.

Hereman,
Diss. Greifswald, 1895
Ein Fall von primarem
Lungencarcinom

HiLDEBRANDT,

Diss. Marburg, 1888
(after Passler)
Zwei Falle von prima-
rem Lungentumor

Hughes,
Loc. cit.

LTJNQ IN-
VOLVED

CLINICAL SYMPTOMS

No heredity. Sudden pain followed
by cough, dyspnoea, dysphagia, hoarse-
ness, loss of weight. Flatness with ab-
sence of voice and breathing over whole
of left chest. Hard supraclavicular
glands. Aspiration: bloody fluid

No heredity. On admission com-
plains of rheumatism and emaciation.
There is some emphysema and bron-
chitis; symptoms of alcoholic neuritis;
clubbed fingers. Nothing points to
disease of lungs. Two weeks before
death for the first time dulness over
left upper lobe with diminished breath-
ing; later absolute flatness over entire
left upper lobe. Some swollen cervi-
cal glands

Increasing emaciation and cachexia.
Hoarseness; flatness with diminished
breathing over left apex. Enlarged
nodular liver; absence of free HCl
in stomach

Father and sister died _ of cancer.
Increasing dyspnoea, rapid loss of
strength, pain in left chest, oedcema of
legs, dilated veins of neck. Impaired
mobility of left chest. Absolute flat-
ness with bronchial and almost am-
phoric breathing over whole of left
chest except apex. Dislocation of heart
to right. Chocolate-colored fluid in left
chest. Duration of illness about one
year

Not given

Always healthy. First sjrmptoms
incontinence of urine and oedcema of
legs. Later severe pain in right chest;
cough. On admission, oedcema of legs,
right arm, and chest and puffiness
of face. Clubbed fingers. Dulness
over right chest; absence of breathing
sounds. Heart pushed to left. Aspi-

CARCINOMA

157

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMARKS

Mucopuru-

Hard tumor starting from

Bronchial

Not men-

lent, no

hilus and surrounding and

and mesen-

tioned

tubercle

following bronchial ramifi-

teric lymph

bacilli

cations

nodes, liver
and kidneys

Often

Soft tumor in left upper

Lung, ven-

Not men-

bloody;

lobe, starting from hilus and

tricular sep-

tioned

under mi-

containing cavity

tum of

croscope

heart, thy-

great

roid, left

numbers

kidney, left

of large,

suprarenal

fatty, flat

and poly-

morph-

ous epi-

thelial

cells, no

tubercle

bacilli.

From

this and

cachexia

and ema-

ciation

diagnosis

was made

during life

Mucopuru-

Cancer of apex of left lung

Right lung.

Not men-

lent, no

liver, mesen-

tioned

tubercle

teric lymph

bacilli

nodes

Scant, not

Left main bronchus leads

Secondary

Pavement

bloody

into soft medullary tumor

nodules in

epithelium

of left lower lobe and along

right pleura

with cell-

bronchial ramifications to

nests

hilus. Entire left lung ate-

lectatic. Encapsulated

bloody effusion in pleura

Not given

Medullary carcinoma of
right main bronchus slightly
infiltrating surrounding tis-
sue. Carcinomatous infil-
tration of right subpleural
lymphatics

Pleura

Cylindrical
and polyhe-
dral cells

Currant

Whole of right lung occu-

Not men-

Diagnosis made dur-

jelly

pied by fungus mass con-
taining irregular cavity in
centre

tioned

ing life from cedcema
of right arm and
bloody sputum after
exclusion of empyema

158

TABLE I

131

132

133

134

135

136

Hyde, Salter,

London Lancet, 1869,
II, July 3, p. 10

Primary Cancer of the
Lung

Jaccotjd,

Legons de Clin. M6d.

1871-72, p. 454
Cancer de Poumon

Japha,

.. Diss. Berlin, 1892
tjber primaren Lun-
genkrebs

Log. ciT.

Loo. CIT.

Log. CIT.

LUNG IN-
VOLVED

CLINICAL STMPTOMS

ration negative,
months

Duration about 6

Always healthy. Swelling of neck
and face several months before any
other symptoms; then sHght dyspnoea,
dilatation of superficial veins of chest
and upper part of body. Later cough,
rapid loss of strength, hoarseness,
laryngeal cough. Complete dulness
in front almost to base; behind to
angle of scapula. Bronchial respira-
tion; no rales. Later cyanosis; absence
of voice and breathing sounds

No heredity. Cough for some years.
Slight oppression on right chest. In-
creasing loss of strength and flesh.
Later dyspnoea, cough, pain in right
chest. Dulness on right lung from
base to angle of scapula; diminished
voice and breathing. Flatness in re-
gion of hilus with bronchial respira-
tion. Diagnosis made during life

Fever, pain in chest, cough. Dulness
over right upper lobe; clubbed fingers.
Later symptoms cavity right apex.
Emaciation

Dyspnoea, pain, cyanosis; pleuritic
effusion. Several aspirations yield
large quantities of clear senim, later
bloody or chocolate-brown. Dilata-
tion of veins of chest

Severe dyspnoea, distress in stomach ;
pain in left chest. Flatness over left
chest with symptoms of pleuritic
effusion. Repeated aspirations yield
brown fluid. Increasing cachexia;
enormous dyspnoea

Pain in right chest; pleuritic effu-
sion. Increasing debility and brady-
cardia. Dulness right upper lobe with
diminished respiration. Ulcerating tu-
mor skin of abdomen. Swelling of
head of right humerus

CARCINOMA

159

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

KEMAKKS

Often pro-

Nearly whole of right lung

_ Not men-

Not men-

Diagnosis made

fuse and

converted into "encephaloid

tioned

during life

bloody,

cancer." Heart pushed al-

contain-

most horizontal. Almost

ing pecu-

complete compression of up-

liar heavy

per cava. Compression of

pellets

trachea and right main bron-
chus. Cavities and soften-
ing in various places

Bloody,

Voluminous mass of "en-

Right lung,

No details

Clinical diagnosis ol

several

cephaloid cancer " at right

pleurae, peri-

tumor of lung made

hffimop-

hilus, penetrating lung and

cardium.

during life from analy-

tyses

connecting with bronchial

around ori-

sis of physical signs

glands. Bronchi and ves-

gin of aorta

and exclusion of other

sels throughout tumor en-

and pulmon-

possibilities

veloped, but not compressed

ary artery

by neoplasm. Bloody effu-

and vein;

sion in pericardium

liver, dura
eroding into
bone and
reaching in-
to temporal
muscle

Occasion-

Medullary tumor with

Single

Very large

ally

cavity in right upper lobe;

lymph node

epithelial

bloody.

bronchiectatic cavities

cells like

no tuber-

pavement

cle bacilli

cells, but

but elas-

author con-

tic fibres

siders alveo-

and pig-

lar epithe-

ment

lium as start-
ing point

Bloody, no

Tumor from hilus follow-

Lymph

Cylindrical

tubercle

ing along bronchial ramifi-

nodes.

and pave-

bacilli,

cations in right lower lobe.

pleura and

ment epithe-

later

Complete conversion of

pericardium

lium originat-

distinct

bronchial wall into carci-

ing from

cancer

noma

bronchial

particles

mucous mem-
brane

Haemor-

Tumor in left lower lobe.

Right lung,

Cylindrical

rhagic

Left lung dislocated and com-

both pleurae,

celled carci-

pressed by several quarts of

regionary

noma prob-

fluid. Pleura thickened

lymph
nodes, liver
and spleen

ably originat-
ing from bron-
chial wall

Bloody, no

Tumor of right upper lobe

Right

Flat pave-

Diagnosis was

tubercle

with necrotic ca^dties com-

pleura, liver ment epithe-

made during life

bacilli

municating with bronchi

diaphragm, Hum with

right hu-

typical can-

merus, skin

cer nests.

of abdomen

Author con-
siders alveo-
lar epithe-
lium as origin

160

TABLE I

137

138

139

140

141

Jessen,

Zentralbl. f . inn. Med.,
Jan. 1906, No. 1

Ein Fall von Karzinom
und Tuberkulose der
Lunge intravitam di-
agnostiziert

JosEFsoN, Arnold,
. Hygiea, 1903, Ht. 2,
p. 139. Zeitschr. f.
Krebsforschung,
1904, I, p. 372.
Schmidts Jahrb., Vol,
280, p. 220, 1903.
Primares Lungen-
carcinom

Kappis, Max,

Munch. Med. Wo-
chensch, 1907, No. 18,
p. 88

Hochgradige Eosinophi-
lie des Blutes bei ei-
nem malignen Tumor
der rechten Lunge

Karminsky,

Diss. Greifswald, 1898

(after Cohn)
Primares Lungencarci-

nom mit verhornten

Plattenepithelien

EIarrenstein,

Charitfe Annalen, Vol.
32, 1908, p. 315

Ein Fall von Kancroid
eines Bronchus und
Kasuistisches zur
Frage des primaren
Bronchial- und Lun
genkrebses

LUNG IN-
VOLVED

L(?)

CLINICAL SYMPTOMS

Heredity of tuberculosis; active
symptoms of tuberculosis. Tubercu-
lar cavity of right upper lobe. After
treatment at Davos, bacilli disappeared
from sputum and tubercular process
seemed arrested. Slight elevation of
temperature and dry cough continues.
Progressive area of absolute flatness
in lower right lung. Dyspnoea; symp-
toms of bronchial obstruction; cedcema
of legs, dilatation of superficial veins.
Increasing cachexia; death from suf-
focation. Clinical diagnosis: cica-
trized tuberculosis of lungs, tubercular
cavity of right apex; carcinoma of
right lung or pleura

Loss of appetite, emaciation, per-
sistent cough. Left lung posteriorly
dulness; diminished respiration and
fremitus. Effusion in left pleura

No heredity. Increasing debility
and _ emaciation; harassing cough,
effusion in right chest. Heart dis-
located to right. Aspiration yields
bloody serum. Dulness with loss of
breathing and voice sounds. Left lung
normal. No reaction with tuberculin.
Blood: hemoglobin 120; reds 6,200,000;
whites 50,560-40,700; polynuclears
56.9; eosinophiles 33-39.5%. Aspira-
tion: sanguinolent serum without eosin-
ophiles. Eosinophilia not explained

No clinical history

Haemoptysis. Pain in right chest,
gradual loss of weight and strength.
Dulness over anterior aspect of right
lung. Bronchoscope showed promi-
nent tumor in right bronchus, com-
pressing it, from which clinical diag-
nosis of tumor of lung was made.
Duration of disease about 10 months

CARCINOMA

161

SPUTUM

AUTOPSY NOTES

METASTASES

MICBOSCOPE

HEMAKKS

Tubercle

Tubercular cicatrizations

Wall of

Scirrhus

bacilli

left lung; tubercular cavity

right ven-

with squa-

right apex. In lower por-

tricle

mous epithe-

tion right upper lobe firm.

lium

fibrous carcinoma. Tumor

surrounds large vessels and

is supposed to originate from

hilus

Raspberry

No record, merely stated

No details

Diagnosis on basis

jelly.

that in centrifuged pleuritic

of sputum made intra

Cancer

effusion cancer cells with

vitam. Author cas-

cells with

mitosis were found

ually mentions that

mitosis

since 1897 there oc-
curred in Sabbatsberg
Krankrenhaus 10
other cases in which
autopsy showed pri-
mary cancer of lung

Scant, mu-

Large carcinoma in right

Lymph

Alveolar

Enormous heaping

coid, no

lower lobe adherent to chest

nodes at

structure ;

of eosinophiles where

tubercle

wall, diaphragm, and peri-

hilus and

large polyg-

there is no tumor

bacilli

cardium. Pneumonic infil-

around

onal epithe-

tration around tumor with

aorta; in

lium

necrosis in centre

sternum,
dorsal ver-
tebrae, ribs,
liver, left
adrenal

No details

Tumor with cavity in left

Two sec-

Typical

upper lobe involving afferent

ondary nod-

horny can-

bronchus

ules in left
upper lobe.
Bronchial
lymph
nodes, left
pleura, left
kidney, left
adrenal and
ventricular
septum of
heart

croid

Haemopty-

Right upper and middle

Liver, stom-

Typical can-

All metastases have

sis

lobes almost completely con-

ach, kid-

croid with

structure similar to

verted into tumor with soft-

neys, brain.

pavement

that of original tu-

ening in centre. Growth

pericardium

epithelial

mor, except metas-

takes origin in large bron-

cells, horny

tases in brain; here

chus immediately below first

and prickle

they have no horny

division of right main bron-

cells and cell

or prickle cells, but

chus where wall of bronchus

nests. _ Prob-

cells are cylindrical

is infiltrated and penetrated

able origin

and in lower layers

by neoplasm

from super-

polygonal, and tumor

162

TABLE I

NO.

AXJTHOK

SEX

AGE

LTJNG IN-
VOLVED

CLINICAL STMPTOMS

142

Kasem-Beck,

Centralbl. f . inn. Med.
1898

Dyspnoea, cough, slight fever, pain
in left chest. Later severe chills.
Dulness over upper portion left chest.
Bronchial breathing

143

Log. cit.

Cough, dyspnoea, diminished expan-
sion of left chest, dilated superficial
veins, enlarged axillary glands. Dul-
ness from left axilla downward ; dimin-
ished voice and breathing; tenderness

144

KiDD,

St. Bartholomew's
Hospital Reports,
1883, XIX, 227-234
A Case of Primary Ma-
lignant Disease of the
Lung

Pain in right chest, cough, clubbed
fingers; bulging of right chest. Di-
minished respiratory movements and
breathing sounds; flatness. Left side
normal. Aspiration: scant, thin, gru-
mous fluid. Hectic temperature, dysp-
noea, ansemia. Duration about 8
months

145

Klubeb,

Diss. Erlangen, 1898
Ein Fall von Bronchial-

carcinom und Lun-

gencyste

Apparently healthy woman. Sud-
den death from extensive burn

146

Kniehiem,

Verhandl. deutsch.

pathol. Gesellschaft,
.. 1909, p. 407
Uber ein primares

Lungenkarzinom

No clinical history. Admitted mori-
bund and died same day

CARCINOMA

163

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMABKS

ficial bron-

has distinct papillary

chial epithe-

structure. Author has

lium

some doubt if this is
genuine metastasis or
a second primary
tumor in brain

Mucoid

Primary tumor left upper
lobe

None

No details

No blood

Diffuse cancerous infiltra-

Bronchial

"Carcinoma

tion in lower f of left lung;

lymph

simplex"

disseminated nodules in up-

nodes,

per third

pleura,
liver, head
of pancreas

Currant

Greater portion of right

Posterior

"Encepha-

jelly.

lung converted into tumor,

mediastinal,

loid cancer"

some

consisting of white, nodular

axillary and

haemop-

masses; small cavities in up-

retroperito-

tysis

per and middle lobes. Sec-
ondary bronchi much com-
pressed. Margin of pleura
over right lobe thickened and
of medullary appearance

neal lymph
nodes

None

Medullary white tumor
completely obstructing right
lower main bronchus, caus-
ing large bronchiectatic cyst
in right lower lobe

None

Glandular
alveolar
structure ;
small cu-
boidal epithe-
lial cells.
Origin from
bronchial
mucous
glands

No details

Large quantity clear se-

Lsnmph

Two differ-

rum in right pleura; right

nodes of

ent types —

lung adherent. Under pul-

right hilus;

one, distinct

monary pleura tumor infil-

retroperi-

alveoles lined

tration following the lym-

toneal and

with cylindri-

phatics. Middle and lower

retrogastric

cal cells, and

lobe filled with diffuse gray

lymph

the other.

tumor masses; numerous

nodes

patches con-

discrete and confluent nod-

sisting of

ules in near vicinity. All

large, irregu-

through the lung miliary

lar polygonal

gray nodules between the

cells arranged

alveoli filled with mucus.

in more solid

Left lung healthy

masses. Pap-
illary projec-
tions prolifer-
ate into the
alveoli;
transition
from flat al-
veolar epithe-
lium to cubic
and high cy-

164

TABLE I

147

148

149

150

KoHNER,

Miinchener Med.
Wochenschr., 1888,
No. 11
Ein Fall von primarem
Krebs der grossen
Luftwege, etc.

Khatz,

Diss. Miinchen, 1892
.. (after Angelhoff)
tjber ein Fail von pri-
marem Lungencarci-
nom mit Metastasen
im Gehirn

Khetschmeh,

Diss. Leipzig, 1904
Uber das primare

Bronchial- und Lun-

genkarzinom

Log. cit.

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Cough, oppression in chest; flatten-
ing of right chest wall. All symptoms
of complete and uncomplicated obstruc-
tion of right main bronchus, absolute
flatness, absence of respiratory and
voice sounds. Diagnosis made during
life

For several months dizziness, pain
in head and chest. Choked disc both
eyes; headache, vomiting. Slight dysp-
noea. Nothing found on lungs. Clini-
cal diagnosis: tumor of brain

Paralysis of recurrent; consolida-
tion and secondary gangrene _ of left
lung; cavities and bronchiectasis; tem-
porary closure of bronchus. Clinical
diagnosis: neoplasm of lung

Clinical diagnosis: pulmonary tuber-
culosis; pleurisy with effusion in left
chest

CARCINOMA

165

AUTOPSY NOTES

METASTASES

MICROSCOPE

Mucoid cyl-
inders
with co-
agulated
blood in
centre ;
raspberry
jelly; oc-
casional
hsemop-
tysis ;
typical
bronchial
casts

None

No details

Complete obstruction of
right main bronchus by tu
mor

Large carcinoma in left
lower lobe

Bronchial carcinoma up-
per left lobe. Gangrene left
upper lobe; almost complete
obliteration left pulmonary
artery. Carcinomatous in
filtration of pericardium ;
carcinomatous degeneration
left vagus; ulcerated can
cerous masses in upper left
main bronchus

Almost entire left lower
lobe occupied by large neo-
plasm infiltrating surround
ing tissue and spreading
from central nodule. Wall

Tracheal
and bron-
chial IjTuph
nodes; both
right pul-
monary
veins

Both lungs
regionary
lymph nodes
and brain

Pericar-
dium; left
vagus

Left frontal
bone, left
kidney, left
suprarenal

lindrical cells.
Large and
small alveo-
lar spaces
filled with
granular ten-
acious mucus,
often con-
taining flat or
round and
polygonal
cells. Larger
bronchi show
no lesions.
Lymph chan-
nels in walls
of lungs and
bronchi con-
tain large
carcinoma
cells. Origin,
epithelium of
alveoli and
bronchioles

Carcinoma

No details

Alveolar
structure,
scirrhous
stroma ; cell
nests and
pearls

Similar to
preceding

Bronchial mucous
glands designated as
probable origin

166

TABLE I

151

152

Loc. CIT.

Log. CIT.

153

154

155

156

167

Loc. CIT.

Kkiegsmann,

Leipzig Klinik, 1877
(after Reinhard)

Kttbb,

Centralbl. f . inn.Med.,

1906, No. 44
Primares tracheobron-

chogenes Karzinom

(Bohemian)

KUHN,

.. Diss. Zurich, 1904
Uber maligne Lungen-
geschwiilste

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Clinical diagnosis: purulent bron-
chitis, bronchiectasis, pleurisy, and
diabetes

Effusion in left chest. First aspira-
tion clear serum; second, bloody
serum

L(?)

Admitted moribund. No clinical
diagnosis

Chronic pneumonia, hydrothorax,
and suspected tumor of left lung

Pain in region of liver. Cough,
chills, fever, anorexia, emaciation.
Dulness from 5th rib downward with
absence of voice and breathing

Pain in chest, obstinate cough,
dyspnoea, rapid cachexia with good
appetite

No heredity. Alcoholic dementia.
Hoarseness with paralysis of left vocal
cord; dyspnoea, dysphagia, stridorous
breathing, emaciation, and cachexia.
Dulness over right apex with dimin-
ished voice and breathing

CARCINOMA

167

AUTOPSY NOTES

METASTASES MICROSCOPE

No details

Purulent
with oc-
casional
haemor-
rhage

No details

of left lower bronchus in-
filtrated with cancerous ma-
terial, ulcerating into lumen

Wall of left lower bron-
chus destroyed by tumor in-
filtrating left lower lobe.
Chronic fibrous pneumonia
and abscess of left lung;
chronic fibrous pleurisy

Uneven nodiilar tumor in
left main bronchus; entire
anterior portion of left lung
occupied by intensely firm,
nodiilar tumor. Bloody se-
nmi in left, clear senim in
right pleura

Large portion of anterior
aspect of right lung infil-
trated with thick, firm tu-
mor extending to 4th, 5th,
and 6th dorsal vertebrae.
Wall of right main bronchus
contains nodulated, partly
ulcerated tumor masses
merging into lung tumor

None

Mucopuru-
lent ; no
blood, no
tubercle
bacilli

Bronchial,
mediastinal,
retroperito-
neal lymph
nodes; left
kidney,
liver, both
suprarenals.
(No bronzed
skin)

Bones of
skull, verte
brse, cerebel-
lum, thy-
roid, myo
cardium,
liver, and
kidneys

Heart dislocated to right;
fluid in left pleura, which is
studded with tumor nodules.
Left lung everywhere infil-
trated with soft tumor.
Similar infiltrations in right
liing with bronchiectases

Right lung except a small
part of upper lobe com-
pletely consolidated. Tumor
masses surround end of tra-
chea and right bronchus, the
latter much thickened, infil-
trated, and compressed

Carcinoma originating
from mucous membrane of
trachea and bronchi, extend
ing along ramifications re-
placing bronchial mucous
membrane and obstructing
lumen

Large tumor in upper right
lobe infiltrating surrounding
lung tissue; smaller tumor
compressing oesophagus and
trachea. Other organs with-
out lesions

Alveolar

structure

Adenomatous
structiire

Origin from bron-
chial mucous glands

Origin from bron-
chial mucous glands
can be demonstrated

Pleura,
pericardium

Regionary
lymph nodes
and right
lobe of liver

No details
except diag-
nosis made
from metas-
tases

No others

Alveolar
structure
with pave-
ment epithe-
lium; cuboid
and cylin-
drical epi-
thelium in
periphery of
alveoli

Alveolar
and papillary
structure.
Cylindrical
cells

No details

Origin probably
surface epithelium of
bronchus

Cylindrical
cells

No details
given

Origin probably
from alveolar epithe-
lium

168

T.IBLE I

158 KUSSMAUL,

Berlin klin. Wochen-
schr. 1879, 413-433
Primares Lungenkar-
zinom ohne Metasta-
sen

159

160

161

162

163

Labb6, Makcel et

BOIDIN,

Bull, et Mem. Soc.
Anatom. de Paris,
1903, No. 8, pp. 743-
747
Carcinome alveolaire
cystique du Poumon

Lammerhirt,

Diss. Greifswald, 1901
Zur Casuistik des pri-

maren Lungencarci-

noms

Log. cit.

LUNG
INVOLVED

CLINICAL SYMPTOMS

Laifle,

Diss. Munchen, 1895
Uber einen Fall von

Mediastinal und Lun-

gencarcinom

Lanceratjx,

Bull, des Soc. Anat.
de Paris, 1858,
XXXIII, 515-520

164

Lange,

Memorabilien,
No. 3

1866,

Blow on left thorax. 7 weeks there-
after cough, pain in region of injury.
7 months later increasing debility
and dyspnoea. Lower half of thorax
in front, flat. Intercostal spaces re-
tracted. Left thorax anteriorly flat-
ness, absence of breathing

First complaint 15 hours before
admission to hospital. Only cerebral
symptoms — headache and vomiting;
slight congestion of optic discs. Clini-
cal diagnosis: cerebellar tumor. Dura-
tion about 2 weeks

No heredity. Slight headaches;
otherwise healthy. Four apoplectic
seizures. Pain in chest; impaired res-
piratory motion of right chest; dul-
ness over right base; no auscultatory
signs. Clinical diagnosis: tumor of
brain

Kick on left chest; some months
thereafter weakness and cough. Some
weeks later kick on right chest followed
by sugillation, cough, bloody expecto-
ration, local tenderness and fever. In-
creasing pain; haemoptysis. Dulness
over anterior right chest; diminished
voice and breathing

Dyspnoea; oedoema of face and neck.
At first nothing on lungs ; later dulness
over right middle lobe with abolished
breathing sounds. Fever, night sweats.
Later respiratory immobility of right
chest; absolute flatness over entire
right chest in front. Cyanosis. Ex-
ploratory puncture negative. X-ray
shows deep shadows all through right
lung

DyspncEa, cough, cachexia. _ Left
apex anteriorly flatness; no voice or
breathing sounds

Sudden attacks of suffocation; in-
tense irritation in throat; rapid ca-
chexia. Dulness over right side with
absence of breathing and voice sounds.

CARCINOMA

169

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

EEMAEKS

Occasion-

Mediastinum and heart

Absolutely

Medullary

ally bron-

displaced towards right.

none

carcinoma

chial

Left upper lobe almost en-

with alveolar

bloody

tirely occupied by large

structure

casts; no

tumor. Aorta adherent to

cancer

but not compressed by tu-

cells or

mor. Bronchi obstructed;

tubercle

bronchiectases. Left pul-

bacilli

monary artery compressed

None

Large cyst in left cerebel-

Glands of

Alveolar

lar lobe filled with fluid con-

hilus

structure ;

taining numerous lympho-

polyhedral

cytes. One large and many

epithelium

smaller cavities throughout

right upper lobe. Walls of

cavities and cyst formed of

cancerous material. Areas

of pulmonic sclerosis around

cancerous tissue. All other

organs healthy

Scant, not

Carcinoma of right lower

Bronchial,

Alveolar

charac-

lobe

mediastinal

structure ;

teristic

and mesen-
teric lymph
nodes ; nod-
ules in brain
and cerebel-
lum

cylindrical
and cuboid
cells

Bloody

Carcinoma of right lower

Right

Pavement

lobe and 5th rib

middle lobe,
bronchial
and supra-
clavicular
lymph nodes

epithelium

Occasion-

Tumor nodules in right

Peribron-

None given

aUy

upper lobe; bronchiectatic

chial, tra-

bloody,

cavities. At bifurcation a

cheal, and

no tuber-

nodule extending into right

mediastinal

cle bacilli

and left main bronchi ob-
structing lumina. Compres-
sion of upper cava

lymph
nodes, liver,
right kidney
and mesen-
teric glands

Abundant,

Left lung converted into

Left

Not given

mucoid;

"jelly-like" mass. Dilated

lower lobe,

occasion-

thoracic veins; cancerous

right lung,

ally blood

thrombus in aorta

liver, kid-

and

neys, supra-

"brain-

clavicular

like" suh-

glands

stance

None

Numerous cancer nodes in
right lung; some softening.
Large cavity at apex. Can-
cer nodule on superior cava.

Right testi-
cle

Not given

170

TABLE I

165

166

167

168

169

170

171

Langhans,

Virchows Archiv.

1871, LIII, p. 470
Primarer Krebs der

Trachea und Bron-

chien

Lardillon,

Thfese de Lyon, 1903
Contribution ^ I' etude

du Cancer des Pou-

Lardillon,
Loc. cit.

Lasegue,
Arch. gen. Paris, 1877,
I, pp. 476-482

Lebert,

Compt. rend. See. de
Biol. 1849-1850, I,
141-150

LeCount, E. R.

Trans. Chicago Path.

Soc. Vol. IV, 1899-

1901, p. 67
Primary Carcinoma of

the Lung

Leech, D. J.

Manchester Medical
Chronicle, XVI, 1892,
p. 178

Not
stated

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

After 5 months painful tumor in right
testicle. Duration of disease 9 months

For a year ssonptoms suggesting
bronchial obstruction — dyspnoea, etc.
but cause of the stenosis could not be
determined. Frequent attacks of suf-
focation in one of which death ensued

No heredity. Enters hospital on
account of rheumatism. Never
coughed. No symptoms pointing to
heart or lungs. Examination of chest
negative. Later some pain in right
chest and cough; sudden profuse
hsemoptysis. Repeated hsemoptyses
thereafter. Gradually increasing dul-
ness over entire right chest. Dimin-
ished voice and breathing. Bloody
serum in right pleura. Left lung
normal. Finally pneumonia of right
base

No heredity. Sense of oppression in
chest, cough, rapid loss of weight and
strength. Increasing dulness over entire
posterior aspect of left lung. Dimin-
ished respiration; puncture negative;
blood normal

Pain, flatness, absence of voice and
breathing over lower part left chest.
Dyspnoea; left thorax increased in size

Clinically merely general symptoms
of asthma

Cough, pain in chest, dyspnoea, ema-
ciation. Bronchial breathing with flat
percussion over upper left chest. Rales
on both lungs. Clinical diagnosis: tu-
berculosis. Duration about 2 years

Always healthy. More or less
cough, oppression in chest, and weak-
ness, nevertheless continued to work
for one year. After that cedoema of

CARCINOMA

171

No details

No tubercle
bacilli or
tumor
elements

Scant, mu-
copuru-
lent, no
tubercle
bacilli

Abundant,
mucous,
no blood

No details

Bloody,

gelati-
nous, no
tubercle
bacilli

Bloody, no
tubercle
bacilli,
no can-

AUTOPSY NOTES

METASTASES

almost perforating it

Medullary tumor at bifur-
cation following along bron-
chial ramifications

Right diaphragmatic
pleurisy. Entire lower lobe
transformed into solid tu-
mor. Tumor of right main
bronchus, penetrating wall
and obstructing bronchus of
right upper lobe

Neoplasm at division of
main left bronchus obstruct
ing both branches. Nodules
bronchial walls and in
lung tissue around bronchi.
Bronchiectatic cavities and
patches of gangrene. Left
lung collapsed and atelecta-
tic — looks like Roquefort
cheese

Large white tumor in-
volving root of left lung and
posterior mediastinum, com
pressing aorta and trachea;
(Esophagus and left vagus
adherent to it

Nodules in both lungs
suppurating and forming
abscesses. Lymphatics
throughout lungs enlarged,
forming visible network of
white strands

Nodules of various sizes
in both lungs; diffuse con
solidation of upper f of left
lobe; cavities throughout
lung

Right pleura thickened
and adherent; lung pressed
upward and backward.
Large cavity in middle and

None

Lymph
nodes at left
hilus

No details

Bronchial
glands

None

Left lung,
bronchial
glands,
glands

MICROSCOPE

Small poly-
hedral cells,
more rarely
cylindrical
cells

Alveolar
structure ;
polymorph-
ous cells often
fusiform.
Mucoid glob-
ules in some
of the cells

Alveolar
structure ;
polymor-
phous cells,
some con-
taining vac-
uoles with
colloid degen-
eration

Not given

No details

Alveolar
structure
with epithe
lial cells;
much degen-
eration.
Channels like
veins filled
with epithe-
lial cells

Scirrhous
cancerous
structure.
Cuboid and

Author traces ori-
gin to bronchial mu-
cous glands

Probable origin
bronchial mucous
glands

Cancer was sus-
pected during life but
the nephritis masked
the diagnosis. Clear

172

TABLE I

172

173

174

175

176

177

Case of Cancer of the
Lung

Lehmkuhl,

.. Diss. Kiel, 1893

tjber primaren Krebs

der Lunge mit Meta-

stasen

Leloib,

Bull. Soc. Anat. de
Paris, 1879, LVI, 719
721

Leopold, Max,

Diss. Leipzig, 1900

Klinischer Verlauf und
Diagnostik des pri-
maren Lungenkrebses

Log. git.

Leopold,
Loc. cit.

1903,

Lepine, J.

Lyons Med.

Vol. 100, p. 18
Cancer primitif du Pou

mon a Globes comes

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

legs, puflBness of eyelids, increasing
weakness and dyspnoea. Dulness
lower part right lung with diminished
vocal fremitus. Slight fever. Clubbed
fingers. Nephritis. 27 ounces clear
serum aspirated, but dulness not di-
minished. Duration of disease about
year and half

All symptoms mainly cerebral —
headache, delirium, insomnia, paralysis
right arm and leg. Nothing abnormal
about chest except some impairment
of respiratory motion on right side.
Clinical diagnosis: hsemorrhagic pachy-
meningitis. Death while patient was
being prepared for operation

Cachexia, pain, rales over left apex.
Nodules in right cervical and inguinal
region

Increasing cough and general debility;
some pain; dyspnoea. Heart disloca-
ted to right. Dulness over both apices;
bloody serum in both pleurae. Dura-
tion 9-10 months. Clinical diagnosis:
phthisis

Cough for years. Flatness and
absence of voice and breathing over
all of right chest. Heart dislocated
to left. Dyspnoea. Bloody serum in
right pleura. Later hard nodules in
skin various parts of the body; one
of these nodules removed showed can-
cerous structure

Pain in right chest; dyspnoea; pro-
fuse expectoration. Hoarseness; paral-
ysis of left vocal cord. Flatness be-
tween 1st and 2d ribs extending to
both mammillary lines. Diffuse bron-
chitis. Later bulging of entire left
chest. Atelectases of left apex with
amphoric breathing. CEdoema of legs.
No fever

Year before entering hospital severe
contusions of left chest. Shortly
before admission severe pain sud-
denly in place of contusion. Dulness,
increased vocal fremitus, absence of

CARCINOMA

173

SPUTUM

AUTOPSY NOTES

METASTASES

MICHOSCOPE

EEMAEKS

cer cells

outer part of right lung with

below dia-

polymor-

serum spoke against

prolongations to apex and

phragm.

phous cells.

malignancy. It is re-

base. Remainder of lung

Uver, kid-

Origin from

markable that there

infiltrated with white new

ney, left su-

alveoli

were no physical signs

growth

prarenal

of so large a cavity

None

Tumor size of a cherry in

Cerebrum,

Cylindrical

Origin bronchial

right lung

cerebellum,
right supra-
renal and
kidneys

epithelial
cells arranged
according to
glandular
type; cells
secrete mu-
cous. Same
structure in
cerebral
metastases

mucous glands

No details

Serous effusion in left

Both

"True car-

pleura. Tiimor at apex of

pleurae, _

cinoma"

left lung

mediasti-
num, cervi-
cal and in-
guinal
lymph nodes

Greenish,

Carcinoma of left lung

Right lower

no tuber-

lobe, both

cle bacilli

pleurae, ret-
roperitoneal
lymph
nodes.
Bronchial
and medias-
tinal glands
not involved

Mucopuru-

Carcinoma of right upper

Skin, left

lent, no

bronchus. Hepatization

pleura.

tubercle

and purulent degeneration

liver, kid-

bacilli

of right lung

neys, left su-
prarenal,
bronchial,
mediastinal
and mesen-
teric glands

Profuse,

Carcinoma of left

Skull, upper

Not given

bloody

bronchus

lobe left
lung, pleura,
liver, bron-
chial, medi-
astinal, epi-
gastric and
mesenteric
lymph nodes

Foetid, mu-

At place of swelling whit-

None

Stratified

copuru-

ish tumor principally locat-

pavement

lent, con-

ed in lung, surrounded by

epithelium

taining

zone of gangrene. Diffuse

with nests of

elastic

infiltration towards hilus.

horny cells

174

TABLE I

178

179

180

Leplate, M

Th^se de Paris, 1888
(Szeyelowski)

Cancer primitif du Pou-

Le Sotjrd,

Bull, et M6m. de la

Soc. Anat. de Paris,

1899, p. 587.
Epith61iome mucoide

primitif du Poumon

LUNG IN-
VOLVED

Letttlle et Bienvenue F
Bull, et Mem. de la
Soc. M6d. des Hop.
de Paris, Vol. XXV,
3e S6rie, 1908, p. 610

Cancer primitif de la

clinical symptoms

breathing at base. Later cough; en-
larged lymph nodes below left clavi-
cle and in both axillae. Exploratory
needle penetrates soft mass. Dilated
veins of left chest and neck. Fever;
rapid decline. Death two months
after first symptoms. Clinical diag-
nosis: pleuro-pulmonary cancer with
secondary gangrene

Always well. 4 months previous to
admission fever, emaciation, pain in
chest, cough. Later dyspnoea, dys-
phagia. Absolute flatness and loss of
voice and breathing over right up-
per chest anteriorly and posteriorly.
Abundant rales. Death from as-
phyxia. Duration about 5 months

No heredity. Severe pneumonia 2
years previous to admission. For
one month nervous disturbances in
both lower limbs. Dulness left apex;
diminished breathing; normal fremi-
tus; intense dyspnoea. Right lung
bronchitis and emphysema. No other
lesions found anywhere. Distinct ten-
dency to obesity. Increasing dyspnoea;
physical signs practically the same.
Death from suffocation 3 weeks after
admission

No heredity. Healthy until Jan.
1907; then loss of flesh, hoarseness,
attacks of dyspnoea lasting 6 hours
at a time. Dulness left lung below
shoulder. Tuberculosis diagnosed.
Shortly thereafter profuse haemoptysis

CARCINOMA

175

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMARKS

fibres, pus

Tumor had penetrated in-

and nu-

terspace to anterior surface

merous

of ribs

bacteria

Bloody

Pleura thickened, forming
solid cap over right upper
lobe. Whole upper lobe
converted into tumor which
on section looks like Roque-
fort cheese. Tumor prolif-
erates into bronchi, which
are compressed and obliter-
ated. Broncho-pneumonia
of lower lobe. Left lung
normal

Bronchial
and tra-
cheal lymph
nodes

No details

Abundant,

Obliteration of left pleural

Secondary

Alveolar

Probably alveolar

mucoid.

cavity; no pleuritic effu-

nodules in

structure of

origin

sion. Both lungs studded

spinal cord

lung appar-

special

with small nodules. On tip

with in-

ently pre-

charac-

of left lung large whitish-

volvement

served; alve-

teristics

yellow hard tumor; no cav-

of some ver-

oles contain

ity. No signs of tuberculo-

tebrae

cylindrical,

sis. Hilus glands scarcely

cuboid, poly-

enlarged. No other lesions

morphous

•

anywhere

epithelial
cells forming
here and
there ridges
and papillary
proliferations
into alveoles.
Epithelial
lining in
single or mul-
tiple layers.
Some alveoles
not filled
with cells
contain mu-
coid fluid.
Some peri-
bronchial
lymph nodes
macroscop-
ically normal,
are found on
microscopic
examination
to contain tu-
mor cells

Mucoid,

Primary cancer of left

Tracheal

Alveolar

Origin from bron-

streaked

main bronchus, infiltrating

and bron-

structure;

chial mucous mem-

with

into lung along lymphatics

chial lymph

polymor-

brane

blood

and into alveoles

nodes; su-

Dhous epithe-

and rasp-

prarenals

ial cells

berry 1 1

176

T.^LE I

LTJNG IN-
VOLVED

CLrNICAL SYMPTOMS

Bronche primitive
gauche

181

Lev^he,

Thfese de Montpellier,

1901
Du Cancer Bronchopul-

monaire primitif

182

Log. cit.

183

LEV:feBB,

Loc. cit.

with violent spells of coughing. Mid-
dle of April violent attack of suffoca-
tion with profuse hsemoptysis. On
admission right lung slightly emphy-
sematous. Left lung behind may be
divided into 3 distinct zones — above
spine of scapula everything normal;
consolidation from spine to point of
scapula with absence of breathing,
extreme vocal fremitus, and consider-
able bronchophony; no rales; abso-
lute flatness. All these symptoms end
abruptly at 8th rib; below this all is
normal. In front normal to 3d rib;
from there dulness to base. A band
6 to 8 cm wide runs from left axilla to
base of lung where there is loud sonor-
ous respiration and increased vocal
fremitus. Diagnosis of cancer of lung
made 3 months before death. No
dysphagia; hardly any pain. Death
from asphj^a. Duration about 5
months

No heredity. In good health until
3 weeks before admission when after
drinking ice-water had chill. Treated
for congestion of lung. Since then
cough, emaciation, intense dyspnoea.
No fever; dulness some rales on right
side. Pains in loins. Clinical diag-
nosis: pneumonia. Dulness base of
right chest; cedcema face, right arm,
and chest. No other signs on lungs.
Aspiration negative. Duration IJ
months

No heredity. Admitted to hospital
for taenia. Slight cough; dulness left
base with diminished fremitus and
breathing. No pain; no dyspnoea.
Later increasing dulness; some dysp-
noea; heart displaced to right. 1500
c.c. clear serum aspirated but dulness
persists; dysphagia. Jaundice; in-
creasing loss of strength and flesh;
enlargement supraclavicular glands.
Clinical diagnosis: cancer of oesoph-
agus

No heredity. Always well. For
6 months intercostal neuralgia right
chest; 4 months ago herpes zoster 3d
to 4th interspace. For 2 months cough ;
no sputum; pleuritic effusion and 1000
c.c. bloody serum aspirated. Abscess
at place of puncture and persistent fis-
tula from which every day about half
goblet foul, sanious fluid is discharged.
Dulness over all of right chest with loss
of fremitus. Incision shows 3d and
4th ribs destroyed and replaced by
neoplasm. Lung is found nodulated
by finger introduced. Diagnosis of

CARCINOMA

177

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

KEMABKS

jelly, no

tubercle

bacilli.

no tumor

elements

Bloody; re-

Clear serum in right

Bronchial

Epithelioma

Author places ori-

peated

pleura. Left lung normal.

and tracheal

with areas of

gin from alveolar epi-

profuse

In lower and middle right

lymph nodes

cheesy degen-

thelium

haemop-

lobe a soft grayish-white

compressing

eration

tyses

tumor surrounded by shell
of lung tissue

trachea.

Mesenteric

lymph

nodes, liver,

pancreas,

spleen

None

Left pleura much thick-

Bronchial,

Somewhat

Said to originate

ened. Nearly whole left

mediastinal

atypical epi-

from alveolar epithe-

lung converted into thick

lymph

thelioma

lium

mass, involving diaphragm,

nodes, com-

nodulated and traversed by

pressing

larger and smaller cavities

oesophagus.
Lymph
nodes at
hilus. Liver
and spleen

At first

Right pleura studded with

Mediastinal

Epithelial

scant,

nodules; right upper lobe

lymph nodes

cancer

several

one solid mass of tumor, pro-

profuse

liferating through incision in

hsemop-

chest

tyses

178

TABLE I

184

185

186

187

L6VI, LEOPOLD,

Arch. g6n. de Med.
1895, Vol. II, p. 346
D'un Cas de Cancer
Broncho-pulmonaire

LOSEH,

Verhandl. d. phys.
med. Gesellschaft,
Wiirzburg, Vol.
XXXIII, 1899, p. 10
Ein Fall von Epitheliom
der Lunge nach Pneu-

LOWENMETER,

Deutsch. med. Wo-
chenschr. 1888, No. 44

LtJBBE,

Diss. Kiel, 1896
Ein Fall von primarem
Lungenkrebs

Not

stated

LTJNG IN-
VOLVED

CLINICAL SYMPTOMS

cancer made. Increasing dyspnoea and
emaciation; profuse haemoptysis; cedoe-
ma of right chest and lower limbs.
Increasing pain. Death. Duration
about 7 months

No heredity. Always healthy. For
6 months cough, pain in right chest,
night sweats, clubbed fingers. Later
oedcema of entire upper body with
cyanosis and dilated veins. Dyspnoea.
Dulness lower third right chest; am-
phoric breathing upper lobe. Dys-
phagia. Aspiration clear yellow serum
from right pleura; no relief

No clinical history. Not even
cause of death

No heredity. Cough; effusion into
right pleura. Consolidation of right
lung. No evidence of tuberculosis.
Rapidly increasing cachexia. Clinical
diagnosis: malignant disease of lung

Diabetes and _ cough for years.
Gradually increasing cough, dyspnoea.
Paralysis of both recurrent nerves. In-
creasing cachexia; bronchitis. Nothing
distinctive found in lungs

CARCINOMA

179

Abundant,
mucoid,
no tuber-
cle bacilli

No details

Mucoid,
later
bronchial
casts and
bloody,
no tuber-
cle bacilli

AUTOPSY NOTES

Right main bronchus
completely closed by tumor;
tumor size of walnut, right
upper lobe, encapsulated
and surrounded by healthy
lung tissue

In connection with a
croupous pneumonia it was
found at autopsy that a dif
fuse increase of connective
tissue had taken place in the
lung in which the pneumonia
had occurred. Numerous
larger and smaller white
nodules were present which
were taken to be newly
formed connective tissue
Under the microscope, to the
astonishment of all, these
nodules as well as the diffuse
infiltration were found to be
extensive tumor formations
Pleura healthy

Nodules and cancerous in
filtration involving nearly
entire right lung. Left lung
perfectly normal

Carcinoma of left upper
lobe; perforation of right
main bronchus and trachea
by tumor. Tumor follows
the ramifications of finer
bronchi throughout entire
lung. Left auricle and up-
per cava penetrated by tu-
mor; left brachial plexus
and aorta surrounded and
compressed. Bulging of
oesophagus by tumor nodules

METASTASES MICROSCOPE

Bronchial
and medias-
tinal lymph
nodes com-
pressing
upper cava
and brachio-
cephalic
veins

Not men-
tioned

Nodules
in dura per-
forated
bones of
skull with-
out causing
cerebral
symptoms
during life

Cervical,
bronchial,
and medias-
tinal lymph
nodes; peri
cardium
and heart
muscle

Alveolar
structure ;
cylindrical,
polygonal
and poly-
morphous
cells

Subpleural
nodules
mostly cylin-
drical cells;
distinct alve-
olar struc-
ture. Simi-
lar nodules
disseminated
throughout
entire lung.
Tumor pro-
liferation

)ng peri-
bronchial fi-
brous tissues.
In alveoles
of lung, nests
and patches
of epithelial
proliferation
which, how-
ever, did not
fill the al-
veoles

Alveolar
structure ;
large epithe-
lial cells

Alveolar
structure;
epithelial
cells often
cyhndrical

Origin probably from
bronchial mucous
membrane

Author leaves
question undecided
whether this was a
simple endothelial or
epithelial prolifera-
tion after pneumonic
inflammation or a real
carcinomatous pro-
liferation. It was
probably carcinoma,
possibly of alveolar
origin. I. A.

Surface epithelium
of smaller bronchi
designated as origin

180

TABLE I

NO.

AUTHOR

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

188

LXJND, 0.

Virchow-Hirsch Jah-
resb. 1879, II, p. 143.
Norsk mag. f. Lage-
vid. R. 3, Vol. VIII,
p. 142
Primar Lungekraft

Nine months before death cough and
emaciation. Later general brain sjonp-
tqms which completely dominated the
clinical picture. Slight dulness and
diminished breathing below right clavi-
cle. Chnical diagnosis: tubercular
disease of lung and brain

189

MacLachlan,

London Med. Gaz.
1843, XXXII, p. 23

Primary Cancerous De-
generation and Ulcer-
ation of the Lung

Dry cough, dyspncsa ; cedoema of eye-
lids, face, and arms. No pain; no
fever. Dulness with absence of voice
and breathing over all of right chest.
Left lung normal. Duration about
3 months

190

Malassez,
Archiv. de Physiol.
1876, II, 353

Both

Extreme dyspnoea

191

Mandlebatjm, F. S.
Personal communica-
tion

Family history of tuberculosis.
Healthy until 1907; then cough, pain
at right anterior base, loss of weight,
dyspnoea on exertion. Examination 6
months later; heart normal; dulness
right infraclavicular space, broncho-
vesicular breathing; flatness and dis-
tant bronchial breathing at right base
posteriorly. All other organs nega-
tive. Clear serum aspirated from
right base. Clinical diagnosis: tumor
of right lung. Increasing cachexia;
partial paralysis of right recurrent
laryngeal

192

Makchiafava,

Rivista clinica di Bo-
logna, Serie II, 1873,
4, p. 150

Di un Cancro primitivo
del polmone a cellule
cilindriche con ripro-
duzione nel cervello a
nell osso frontale

Both

Harassing cough, emaciation, brain
symptoms. Clinical diagnosis: chronic
tubercular pneumonia. Duration of
disease about 8 months

193

Matne,

Dublin Hospital Gaz.
1857, 2. Proceedings
Path. Soc. Dublin,
1856-7, p. 191

Lancinating pain in chest, cough,
dyspnoea, cachexia. Dilatation_ of su-
perficial veins. Impaired respiratory
motion of right chest. Flatness and
bronchial breathing over all of right
chest. Duration 15 months

194

McMtr>rN,

Irish Hospital Gaz.
1874, II, 69-71

Dyspncea; chronic bronchitis. Dul-
ness over entire left chest with feeble
voice and breathing sounds. Dilata-
tion of superficial veins. Increasing
pain. Enlarged glands in left axilla

195

M£N]& TRIER,

Always well. Debility, loss of flesh,

CARCINOIVIA

181

No details

Scant

No details

Abundant,
bloody,
no tuber-
clebacilli,
no tumor
elements

No details

Scant, later
gelati-
nous mu
cus

Mucous,
later

abundant
hsemop-
tyses

No details

AUTOPSY NOTES

Right main bronchus per-
forated and obstructed by
cancerous tiimor penetrat
ing into right upper lobe at
the hilus

Whole of right chest filled
with firm tumor containing
numerous ca\aties. Hard
nodular tumor at root of
right lung compressing right
main bronchus, upper cava
and right pulmonary artery

Numerous nodules in both
lungs partly confluent and
forming larger tumors

Entire lower right lobe
converted into tumor in cen-
tre of which is large cavity
containing necrotic matter.
Communication between tu-
mor and bronchus of large
size, the tumor growing di-
rectly into lumen of bron-
chus

Both lungs studded with
tumor nodules, some with
central breaking down and
various kinds of necrosis

Large white tumor _ at
hilus of right lung involving
nearly all of right lung, which
consists of hard white can-
cer masses interspersed with
bluish-gray lung substance.
Bronchi dilated

Right lung normal. Left
lung converted into a pur-
plish shrunken mass studded
with white nodules; cavity
in centre of lung. Left bron-
chus compressed

Large tumor in right up-

METASTASES

Lymph
nodes of
hilus and
cerebellvun

Bronchial
and medias-
tinal lymph
nodes

None out-
side of lung;

None

Frontal
bone, brain,
cerebellum

Mediastinal
lymph
nodes, com-
pressing up-
per cava

Axillary
and bron-
chial lymph
nodes;
pleura,
liver and
spleen

Left lung,

MICBOSCOPE

Simply
stated: carci-
noma

No details

Alveolar
structure
with single
layers of cy-
lindrical cells

TjT)ical
carcinoma
squamous
cell type with
distinct cell
nests and
incomplete
attempts at
formation of
homy pearls

Alveolar
structure ;
alveoli lined
with tjTjical
cylindrical
cells, but
filled with
polymor-
phous cells

No details

Alveolar

182

TABLE I

196

197

198

199

ProgrSs M6d. 1886
436-437
Cancer primitif du Pou-
mon

MeRKLEN & GiRAED,

Bull, et M6m. de la
Soc. Med. des Hop.
de Paris, Vol. XVIII,
3d S. 1901, p. 760
Cancer primitif des
grosses Bronches

Mbunieb,

Arch. g6n. de" M6d.

Vol. I, p. 208
De la Pneumonia du

Vague

MlNSSEN,

.. Diss. Kiel, 1900
Uber prim§,ren Lun-
genkreba

MOIZARD,

Bull, de la Soc. Anat
de Paris, 1875, pp.
732-3
Cancer des Ganglions
Bronchiques et du
Poumon droit; enva-
hissement de la veine
cave superieure; Pleu
resie

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

pain in right chest. Persistent diar-
rhcea, cedcema of upper extremities and
face. Dry cough. Dulness over right
apex. Clinical diagnosis: some ob-
scure visceral cancer with probable
metastases in lungs. Sudden death.
Duration about 4 months

Mother died of cancer. Perfect
health until August, 1900. First
symptom: difficulty in breathing both
when resting or exercising. After a
cold, violent cough and severe attacks
of suffocation. Hoarseness, dysphagia.
Increasing dyspnoea; almost complete
aphonia. Dulness over nearly entire
right lung. Liver pushed downward.
No pleuritic effusion. Total absence
of breathing over right apex; lower
down intense bronchial respiration with
crackling rales at base. Diagnosis of
broncho-pneumonic cancer was made
during l^e. Death in an attack of
suffocation. Duration about 7 months

Gout and bronchitis for years.
Later dyspnoea, increasing debility,
loss of flesh, and severe cough. No
fever. Pleuro-pneumonia at right base
a few days before death

Always well until influenza with
pain m right chest, cough, and expec-
toration. Since then increasing dysp-
ncea and debility. Dulness over right
apex; bronchial and amphoric breath-
ing. Stridorous respiration and cyano-
sis. No fever. Sudden death from
haemoptysis. Duration of disease
about 10 months. Clinical diagnosis:
emphysema and pulmonary tubercu-
losis

Cough; swelling of extremities and
face. Right external jugular dilated,
not pulsating; right radial artery
weaker than left. Heart normal.
Dulness over lower § of right lung
posteriorly with diminished voice and
breathing. Superficial veins dilated.
Fluid in right chest. Diagnosis: pleu-
ritic exudate due to mediastinal tumor
at root of lung with compression or
thrombosis of superior vena cava

CARCINOMA

183

AUTOPSY NOTES

METASTASES

MICROSCOPE

per lobe proliferating into
spinal canal. Right bron-
chus and upper cava com-
pressed; both vagi envel-
oped in tumor

both

pleurae,

regionary

lymph

nodes, liver,

spleen, both

suprarenals

Mucopioru-
lent,
streaked
with
blood

No details

Bloody,
no tuber-
cle bacilli

Trachea adherent to
oesophagus; both surrounded
by enlarged lymph nodes.
Primary tumor in right
main bronchus; lumen al-
most entirely obstructed by
soft, polypoid growth with
pedicle at bifurcation. PrO'
fuse degeneration of sur-
rounding mucous mem-
brane, thickened, white, and
studded with bluish nodules
Left bronchus and lung nor-
mal. Right pleura adherent
On section bronchi filled
with ichorous fluid. Lung
tissue studded with numer-
ous white cancer nodules

Mass of neoplasm at right
hilua infiltrating and ob-
structing main lower bron-
chus. Entire lobe con-
verted into cheesy, friable
mass containing small cav-
ities filled with pus and sur-
rounded by necrotic tissue
Pneumonic hepatization at
the periphery. Whole looks
"like sponge filled with
pus." Right vagus merged
into neoplasm

Necrotic carcinoma of
right bronchus perforating
pulmonary artery; bronchi-
ectatic cavities

No metas-
tases any-
where
throughout
entire body

No details

structure
containing
cylindrical
and poly-
morphous
cells and mu-
coid degen-
eration

Large bron-
chial vegeta
tions, fibrous
stroma, mU'
cous in some
places ; large
alveoles and
ramifying
anastomosing
cells, cuboid,
cylindrical,
and polyhe-
dral. Struc-
ture of pul-
monary nod-
ules about
the same

Cylindrical
cells

Origin from bron-
chial epithelium

Dark,

clotted
blood

1000 c.c. of clear serum in
right pleura. At root of
right lung a whitish medul-
lary mass surrounding but
not compressing right bron-
chus and extending into the
superior vena cava, ob-
structing its lumen. _ Siini-
lar medullary tumor in mid-
dle lobe. Cerebral ventri-
cles distended with pus

Left pleura,
bronchial
and retro-
peritoneal
lymph
nodes; pan
creas, spleen
and kidneys

None men-
tioned

Alveolar
structure,
glandular
cells sur-
rounding lu-
men and se-
creting mu-
cus

Not given

Origin from bron-
chial mucous glands

184

TABLE I

200

201

202

203

204

205

Moore,

London Path. Soc.

XXXII, p. 32
Cancer of Right Lung

with Embolism

Middle Cerebral

MOBELLI,

Deutsch. Med. Woch
1907, May 16, p. 805
Ein Fall von primiirem
Lungenkrebs

MORIGGIA,

Rivista Clin, di Bolo-
gna, 1873, Serie 2,
III, 5, p. 150
(Quoted after Meissner)

MxJLLER, HeINRICH,

Diss. Freiburg, 1904
Zwei Falle von pri-
marem Lungencarci-
nom

Loc. CIT.

MiJ'SER,

Mitteilungen aus den

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

Definite symptoms of pressure on
right bronchus; enlarged and hard
cervical lymph nodes. Aspiration
yields bloody fluid. Diagnosed from
this during life. Shortly before death
aphasia and right hemiplegia

No heredity; always healthy. After
cold with fever and cough, increasing
loss of flesh and strength. Chill,
severe pain in right chest, dyspncea.
Consolidation at right base with some
pleural effusion. Endocarditis; dis-
location of heart to right. Duration
about 7 months

Headache and increasing spasmodic
cough. Nausea, depression, emacia-
tion. After 3 months neuralgic pain
in lumbar and hip regions. On ad-
mission to hospital signs of a chronic
tubercular pneumonia. After 4 weeks
delirium and intense thirst. Clinical
diagnosis: tubercular meningitis.
Death after 2 months

For some months considerable ema-
ciation, pain in right leg, foot, and back.
Lungs, with the exception^ of slight
emphysema, normal. Clinical diag-
nosis: sciatica, lumbago, and arterio-
sclerosis. Some time later hard gland
above right clavicle. Still later, high
fever, dulness, and bronchial breathing
at right base. Sudden coUapse. With
appearance of gland, tumor of lung
was suspected. Duration about 5
months

Enters hospital for psychiatric dis-
turbance. Lungs normal at this time.
Later increasing emaciation; rales at
both bases. Tumor on left chest ad-
herent to rib; glands in left axilla.
Death in marasmus; duration of dis-
ease about 3 months

General malaise, dyspnoea, cough,
fever with chilliness, loss of weight,

CARCINOMA

185

No details

Bloody,

shows
diplococci

No details

On surface of right lung
hard white new growth in
patches, penetrating into
lung and continuous with
similar dense tissue spread-
ing into lung from root and
pressing on main bronchus

Both lungs studded with
small white nodules corre-
sponding to blood vessels,
and connective tissue
strands which macroscop-
ically suggested fibrous re-
sults of pneumonic processes.
Nothing pointing to tumor

AUTOPSY NOTES

METASTASES

Mediasti-
nal, bron-
chial, and
cervical
lymph
nodes

Absolutely
no others

Pleura, heart, pericardium
normal. In lungs numerous
larger and smaller nodules
confluent and degenerated;
small cavities in centre. In^
ner surface left frontal bone
a soft whitish prominence
Meninges healthy. Numer-
ous small nodules through-
out brain

Large tumor with soft-
ened and necrotic centre
in right upper lobe. Right
main bronchus infiltrated
and obstructed by tumor.
Upper lobes both lungs
studded with small nodules,
Some tuberculosis

Scant, mu-
copuru-

No others
mentioned

Bronchial
lymph
nodes, ribs,
kidneys, and
adrenals

MICROSCOPE

Bands of
fibrous tissue
with alveoli
containing
epithelium, in
some parts
distinctly
columnar

Nests of epi-
thelial cells
in lymph
spaces of fi-
brous tissue
and adven-
titia of blood
vessels, also
epithelial
clusters fill-
ing alveoles,
in the alveo-
lar septa and
around blood
vessels and
smallest
bronchi.
Cells re-
semble glan-
dular cells

Alveolar
structure
lined with cy-
lindrical cells

No details

Interesting features
of this case are the
youth of the patient
involvement of both
lungs and the fact
that the diagnosis
could only be made
with the aid of the
microscope

Origin bronchial
mucous glands

Large tumor in left lung Only in
extending to pleura; no con- brain
nection with bronchus. Tu-
mor penetrates chest wall
and extends under pectora-
lis. Gangrene of right lower
lobe. At autopsy tumor is
diagnosed as osteoma of rib

Large tumor left upper
lobe containing cavity. Af

Bronchial
lymph

Typical
carcinoma-
tous alveolar
structure ;
polygonal
epithelium

No details

Author designates
alveoli as origin of
tumor

186

TABLE I

206

207

208

209

210

Hamburgischen
Staats-Kranken-
Anstalten, Vol. VIII,

.. Heft 5, 1908

tjber den prim^ren
Krebs der Lungen
und Bronchien

Log. cit.

LOC. CIT.

MtJSER,

Loc. cit.

Log. cit.

LUNG IN-
VOLVED

clinical symptoms

severe headaches. Choked discs; vari-
ous cerebral symptoms. Small area
of dulness left upper lobe in front;
otherwise both lungs normal. X-ray
shows spherical shadow extending
from left hilus. Duration about 18
months. Clinical diagnosis: tumor
of left upper lobe with metastases in
cerebellum.

Note. — Case II of this author is
not included as there is no autopsy
and it is not certain whether tumor
is primary in the lung

Increasing dyspnoea, pressure, pain.
Later enlarged supraclavicular glands.
Manubrium oedoematous and exceed-
ingly tender to touch. Right lung
from 2d rib down complete flatness
and diminished respiration. X-rays
show large shadow to right of sternum.
Duration of disease about 3 years

Cough, pain, loss of weight and
strength. Various paralytic symp-
toms. Over middle lobe flatness and
diminished respiration. Secondary tu-
mor in liver. Diagnosis made during
Ufe. Duration about 3 months

After influenza severe cough
and bloody sputum. Rapid mental and
physical decline. Later vertigo and
paralysis. Qildoema of both lungs;
clubbed fingers. Flatness right lower
lobe; diminished voice and breathing
sounds. On exploratory thoracotomy:
a cavity filled with bloody pus and
containing tumor particles consisting
of polygonal and cuboid cells. At
first some improvement; then rapid
decline and death. Duration about
2 years

Two years before admission pain in
right chest ; for three months loss of
weight, slight fever, cyanosis, dysp-
noea, cough. Swollen lymph nodes
in right axilla. Flatness right chest
below 4th rib; diminished respiration
in front; bronchial and amphoric
breathing behind. Exploratory punc-
ture shows characteristic granular
cells from which diagnosis of tumor of
right lung is made

Pain, loss of weight and strength.
Diminished respiration and slight area
of flatness on right chest about 2d

CARCINOMA

187

lent,
pathog-
nomonic
granular
cells

Sputum
contained
charac-
teristic
cells

At times
bloody;
charac-
teristic
granular
cells

Greenish,
mucoid,
fat drop-
lets

ferent bronchus infiltrated
with tumor and ulcerated

Bloody,
raspberry
jelly,
profuse
hgemop-
tysis

Bloody,
charac-
teristic
granular
cells

None

AUTOPSY NOTES

METASTASES

Large carcinoma of right
middle lobe extending into
lower lobe

Bloody serum in right
pleura. Large tumor in
middle and upper right
lobes. Carcinomatous infil-
tration afferent bronchus

Carcinoma of right lower
bronchus, tumor cavity al-
most completely filling right
lower lobe

Large tumor near right
hilus starting from bronchus

nodes and
cerebellum

Hilus and
supraclavic-
ular glands

Bronchial
and epigas-
tric lymph
nodes, liver,
5th rib, in
number of
vertebrge.
Compres-
sion of spi-
nal cord

Right lung
and cerebel-
lum

Liver and

lymph

nodes

MICROSCOPE

No details

Carcinoma

No details

Operation : Tumor
of right lung contain-
ing cavity. As much
of tumor as possible
removed. Recovered
and has remained well
for a year

188

TABLE I

NO. AUTHOR

LUNG IN-
VOLVED

211

212

213

214

215

Log. cit.

Loo. CIT.

Log. CIT.

216

Log. CIT.

217

Log. GIT.

218

Log. git.

CLINICAL SYMPTOMS

to 3d rib. Otherwise both lungs nor-
mal. No cough. Death from sudden
collapse. Duration about 2 months

Emphysema for years. Recently
loss of weight and strength; cyanosis;
dulness over left base with diminished
respiration. Effusion in right pleura

Dyspncsa, cough, pain, rapid loss of
weight. Left chest flattened, impaired
respiratory motion ; flatness, no breath-
ing sounds. After aspiration 1050 c.c.
brown serum, flatness remains

Sudden cough, expectoration, slight
pain. Loss of flesh and strength.
Dulness over left upper lobe with
feeble breathing sounds and impaired
respiratory motion. Duration about
10 months

Cough, rapid emaciation. Dulness
over entire left upper lobe; diminished
breathing, bronchial toward hilus.
Duration about 2 months

Cough, expectoration, increasing
loss of strength and weight. Flatness
over all of left lobe; impaired respira-
tory motion; loss of breathing and
voice sounds

Cough, expectoration, loss of weight
and strength. Dulness over left upper
lobe and sternum; a few large rales.
Greatly diminished respiration. Dura-
tion about year and half

Cough, expectoration, loss of weight.
Retraction right upper chest; flatness
right upper lobe with diminished
breathing sounds; no vocal fremitus.
Emphysema and bronchitis in remain-
der of lungs

Cough, pain, loss of weight. Dul-
ness over left lobe posteriorly with
diminished voice and breathing

CARCINOMA

189

AUTOPSY NOTES

METASTASES

MICHOSCOPE

No details

Granular

fatty cells

Mucoid,
bloody;
no as-
sured
granular
cells

No details

Mucoid,
often
bloody,
some-
times
prune
juice. No
tubercle
bacilli
but gran-
ular cells

Nothing
charac-
teristic

Mucoid

Bloody
with char-
acteristic

Carcinoma left lower lobe
starting from main bronchus

Left upper and lower bron-
chi infiltrated with tumor
penetrating into lung and
forming nodules

Ulcerated carcinoma of
left main bronchus with tu-
mor containing cavity in left
upper lobe

Large carcinoma starting
from left main bronchus

Carcinoma from left main
bronchus involving nearly
whole of left lower lobe.
Embolus left pulmonary ar-
tery; aneurysmatic dilata-
tion left ventricle

Large carcinoma from left
main bronchus; bronchus
left upper lobe completely
closed by tumor

Carcinoma at first bifurca-
tion right main bronchus, al-
most completely obstructing
right upper bronchus and
proliferating along bron-
chial ramifications through
upper lobe. Bloody serum
in pleura

Carcinoma of left main
bronchus involving nearly
all of left lower lobe. Puru

which com-
press recur-
rent laryn-
geal and
vagus

Liver

Both

pleurae,
bronchial
and tra-
cheal lymph
nodes

Bronchial,
tracheal,
and medias-
tinal lymph
nodes

Mediastinal
lymph
nodes com-
pressing re-
current

No details

Bronchial
and tracheal
lymph
nodes, liver
and dura.
Pyloric car-
cinoma is
also found

Pericar-
dium, heart,
kidneys, and
suprarenals

Small carci-
noma in
stomach

No details

Author implies
that pyloric carci-
noma is distinct and
independent of lung
tumor. Microscopic
structure unfortu-
nately not given

190

TABLE I

219

220

221

222

223

224

MtJSER,

Loc. cit.

Loc. CIT.

MrrssELiER,

Gaz. M6d. de Paris

1886, 159
Cancer primitif du Pou-

mon

MUSSBR, J. H.

Univ. Penna. Med
Bull. Vol. XVI, Oct
1903, No. 8, p. 289
Primary Cancer of Lung

Loc. CIT.

Maun, I.

Deutsch. med. Zeit.

XXVI, 1905, p. 537
Ein Fall von primarer

Krebsentwickelung in

den Bronchien

F 76

LUNG IN-
VOLVED

Both

CLINICAL STMPTOMa

Cough, pain, loss of weight. Im-
paired respiratory motion. Dulness
and diminished voice and breathing
over left lower lobe. Duration about
2 years

Always healthy. Recently cough,
dyspnoea. Dulness, diminished bron-
chial breathing, impaired respiratory
motion over right upper lobe

No heredity; always well. Pain in
right shoulder; later small hard tumor
below right clavicle; subsequently sim-
ilar tumor below left clavicle. Irreg-
ular area of dulness in right chest
posteriorly with feeble respiration.
Paraplegia. No cough; no dyspnoea.
Duration about 7 months. Diagnosis
made during life from the bloody spu-
tum, pain and tumors below clavicle

No heredity. Clinical symptoms
those of pleuropneumonic infection.
SUght fever, physical signs of effusion;
aspiration negative. Exploration re-
vealed nodule in lung. Marked leu-
cocytosis. Cachexia very late. Dura-
tion less than 3 months

_ No heredity. Sore throat _ only at
night and in recumbent position. In-
digestion, dyspncea, loss of flesh and
strength. Moderate cough causes
bringing up of large amount of fluid.
Slight pleural friction in right axillary
region only physical sign on lungs.
Nothing characteristic in blood. Signs
of bronchitis and pleuritis; rales at
both bases. Intense dyspnoea; in-
creased leucocytosis. Duration about
5 months

Lues 20 years ago. Recently loss
of weight and strength; repeated
haemorrhages. Persistent pain with-
out swelling in all joints. Near left
costoclavicular articulation a tumor
size of a walnut, hardly movable,
slightly fluctuating. Dulness over
both supraspinous fossse; dulness left
with diminished respiration.

CARCINOMA

191

BPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMARKS

fatty

lent exudate in left pleural

granular

cavity

cells

Bloody,

Nearly whole of left lower

No details

fatty

lobe converted into hard

granular

cancerous mass. Bloody

cells

fluid in left pleura

Purulent,

Carcinoma of right upper

Bronchial

No details

bloody

bronchus; obliteration of

lymph

with

pleura. Bronchiectasis and

nodes and

"Fett-

bronchopneumonic areas in

liver

korn-

both lower lobes

chen"

Currant

Several larger and smaller

No others

No details

jelly

tumors softened in centre in
upper portion right lower
lobe

No details

Massive tumor of right

Left lung,

■
No details

A second case is

lower lobe

liver, tho-
racic lymph
nodes

not included because
there was no autopsy
but there is no doubt
that it was a similar
case

Not bloody,

Diffuse yellowish gray in-

Cervical,

General al-

No anatomical

no tuber-

filtration uniformly through-

bronchial,

veolar ap-

cause for the orthop-

cle bacilli

out both lungs. No pleu-

tracheal,

pearance of

noea and sore throat

ritic effusion

and retrope-

lung re-

could be found. Clin-

ritoneal

tained; fre-

ical diagnosis was tu-

lymph

quent areas

berculosis

nodes

of necrosis.
Flat epithe-
lial cells re-
sembling al-
veolar epithe-
lium; in older
portion dis-
tinctly papil-
lary arrange-
ment and cy-
lindrical cells

Abundant,

Left lung adherent; near

Areas of

Abundant

Practically no pain.

mucopu-

posterior border large cav-

neoplasm in

firm stroma ;

no dyspnoea, and

rulent;

ity; numerous bronchiec-

pericardium

alveolar

nothing characteris-

no tuber-

tatic cavities containing pus.

and left ven-

structure

tic. Only significant

cle bacilli;

Right lung normal. A mass

tricle

filled with

symptoms initial hae-

repeated

the size of an orange at bi-

polymorph-

moptysis and rapidly

hsemop-

furcation of main bronchus;

ous epithe-

increasing cachexia

tyses;

similar tumor at lower end

lial cells;

later

of trachea toward left. Near

plentiful

192

TABLE I

225

226

227

NEtTMEISTEB,

Miinch. med. Wo
chenschr. No. 36, 52,
1905, p. 1721
Ein Fall von primarem
Plattenepithelkarzi-
nom der Lunge, etc

Oberthub,

Revue Neurol. Vol
X, Paris, 1902, p. 485

Oesteeich,

Berl. klin. Wochen-
schrift, 1892, p. 104,
Demonstration

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Cough. Pain left base. Aspiration,
clear blood. Diarrhoea. No fever:
Haemoglobin 40, leucocytes 15,000.
Death from exhaustion. Duration
about one year. First diagnosis was
tuberculosis, then pneumonia with
bronchiectasis. Only very late during
life was there a suspicion of malignancy

Had pleurisy some years ago. Weak,
cachectic; suffered for year with pain
in right shoulder joint. Clinical diag-
nosis: pulmonary tuberculosis and tu-
berculosis of right shoulder joint

No heredity. At age of 27 both
ovaries removed for cystic degenera-
tion. About middle of 1899 she com-
plained of vague pain along spine, in
shoulder and chest even on slightest
effort. Loss of appetite and flesh.
End of year, frequent painful attacks,
cough, bloody sputum. Diagnosis at
that time tuberculosis. Patient then
commenced to drink large quantities
alcoholic liquors. Increasing dyspnoea,
CBdcemaof lower extremities. Nervous
symptoms now predominate, painful
cramps in both upper and lower ex-
tremities and along spine which pre-
vent sleep. Rapid atrophy of muscles.
Soon not only walking but almost
every movement becomes impossible;
intense general hypersesthesia. Details
of neurological examination omitted.
Continuous dyspnoea ; absolute flatness
over whole of left lung. Total absence
of breathing except some amphoric
respiration at hilus. Dulness at base
of right lung with friction; harsh
breathing throughout and some rales.
Continuous sweating. Chnical diag-
nosis: alcoholic polyneuritis and pul-
monary tuberculosis

Malaise for some time. Effusion
of clear serum in right pleura. In-
creasing dyspnoea, cyanosis, cedoema of
upper body

CARCINOMA

193

AUTOPSY NOTES

METASTASES

MICKOSCOPE

bloody

No details

origin of left main bronchus
a } cm. whitish yellow mass
destroying the cartilages
and penetrating into lumen
of bronchus

Anatomical diagnosis: tu-
berculosis of left lung; bron-
cho-pneumonia of right; pu-
rulent bronchitis; cheesy
degeneration of right supra-
renal, tubercular arthritis
right shoulder joint

Only in
right shoul-
der joint

Abundant,
mucopu-
rulent,
often
streaked
with
blood,
but no
"currant
jelly."
Sputum
not ex-
amined
micro-
scopically

No details

Large quantity yellow
serous fluid in left pleura;
small quantity in right.
Cancerous pleurisy ; cancer
ous lymphangitis. Left lung
retracted, atelectatic, and fi'
brous at apex. Whole left
lower lobe and hilus a mas-
sive cancer, soft in interior
and fibrous exteriorly.
Large and medium size
bronchi disappear entirely
in tumor. Small secondary
nodules especially near hilus
in right lung around bron
chi. Swollen mediastinal
lymph nodes envelop base
of trachea and main bronchi
Pericardium and myocar-
dium contain miliary nod-
ules; innumerable miliary
nodules in skin and muscles
all over body

Carcinoma of right main
bronchus involving lung
along bronchial ramifica-
tions; some obstruction of

2 secondary
nodules in
uterus; mill'
ary nodules
in both kid-
neys, supra-
renals, pan-
creas, liver,
retroperito-
neal glands
pericardium,
myocar-
dium, skin,
and muscles

karyokinesis.
Origin from
bronchial
mucous mem-
brane

Capsule of
joint showed
no tuberculo-
sis but infil-
tration with
typical can-
croid pearls.
In the lung
innumerable
foci of carci
noma of can^
croid type
which could
not be differ
entiated from
the tubercu-
lar tissue
which was
everywhere
intermingled

Glandular
epithelium
with cylindri-
cal cells with
many karyo
kinetic figures

Discussion whether
primary in lung.
Probable origin bron-
chial mucous glands.
Microscopic study of
nerves and muscles,
also mUiary nodules,
all show same char-
acter as primary tu-
mor. Nothing in
brain, medulla or me-
ninges. Lesions in
nervous system and
muscles by their pres-
sure cause degenera-
tion of nerve and
muscle fibres with
pseudo-hypertrophy
in the latter

No details

194

TABLE I

228

229

Otten,

Fortschritte auf dem
Gebiete der Roent-
genstrahlen, Vol. IX.
Heft 6, 1906, p. 369

Zur Roentgen-diagno-
stik der primaren
Lungencarcinome

Log. cit.

230

231

232

233

Log. err.

Otten,

Loc. cit.

Log. cit.

Loc. CIT.

234

235

Log. cit.

Loc. CIT.

SEX AGE

LtTNG IN-
VOLVED

CLIiaCAIi SYMPTOMS

Pain in right chest, cachexia, CEdcema
of right arm; dilated veins over right
chest and belly. Dulness and absence
of breathing over right upper lobe.
Some dyspnoea; no cough

No heredity. Cough and expectora-
tion for years; otherwise well. Diag-
nosis at first, tuberculosis. Later pain
in right shoulder, cough, dyspnoea, cya-
nosis of upper body. Enormous dila-
tation of superficial veins; cedcema of
arm. Cachexia. Dulness right upper
lobe with signs of cavity. No fever

Father died of carcinoma of stomach.
For 4 months pain in right chest,
cough, expectoration; general debility.
Enlarged axillary glands. Dulness
right upper and middle lobes. Dura-
tion of disease about 5 months

Cough and mucoid expectoration

for several years. Increasing dyspnoea,
emaciation, and debihty. Enlarged
glands in both axillae. Dulness over
nearly entire left lung. Some fever.
Death after about 5 months

Mother carcinoma of uterus. Always
well. For 6 weeks increasing weakness,
loss of flesh, dyspnoea, cough, pain
in chest and back; attacks of suffo-
cation; some fever. Dulness right
middle and lower lobes. Impaired
respiratory motion. Haemorrhagic ef-
fusion in right pleura

No heredity; always well. For
about On months bloody expectoration,
loss of weight, cough, cyanosis, dysp-
noea; moderate fever. Enlarged axillary
and cla\ricular glands on right side.
Hoarseness. Consolidation of right
upper lobe

No heredity. For .5 months cough,
dyspnoea, increasing debility, and loss
of weight. Signs of consolidation of
right upper lobe with dry pleurisy in
right chest. Bloody effusion in left
chest. Paresis of left recurrent

No heredity. For several months
increasing weakness and loss of flesh.

CARCINOMA

195

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

EEMAEKS

left bronchus. Extensive
gangrene of lung; bronchiec-
tasis. Compression of up-
per cava, aorta and oesopha-

gus

None

Carcinoma of right upper
lobe. Thrombosis right
subclavian and axillary veins

Glands of
hilus and
right axilla

No details

Mucopuru-
lent

Carcinoma of right upper
lobe with cavity in centre.
Thrombosis upper cava and
both internal jugulars

Lymph
nodes at
root

No details

Carcinoma of right main
bronchus and infiltration of
upper and middle lobes

Bronchial
lymph
nodes and
liver

No details

Mucoid

Carcinoma of entire left
lung

Liver, hi-
lus, and axil-
lary lymph
nodes

No details

Purulent

Carcinoma of large bron-
chus of right side with infil-
tration of entire middle lobe

Liver, right
adrenal

No details

Bloody

Carcinoma of right bron-
chus infiltrating upper and
middle lobes

Axillary
and clavicu-
lar glands

No details

Mucoid

Carcinoma of left main
bronchus infiltrating a large
part of left upper lobe.
Pneumonia of right lower
lobe

Glands of
left hilus

No details

No detaUs

Carcinoma of left main
bronchus infiltrating large

Bronchial,
tracheal.

No details

196

TABLE I

236

237

238

239

240

241

242

Loc. err.

Log. cit.

Loc. CIT.

Pabssleb,

Virchows Arch. Vol.
.. 145, 1896, p. 191
Uber das primare Kar-

zinom der Lunge

Loc. CIT.

Not
stated

LXTNG IN-
VOLVED

CLINICAL SYMPTOMS

Cough, pain in left chest, dyspnoea,
and cyanosis. Enlarged left axillary
and clavicular glands. Dilated veins
left shoulder. Dulness over left upper
lobe. Absence of breathing over all
of left chest. Paralysis left recurrent

No heredity. For about 2 months
cough, expectoration; later dyspnoea
and palpitation. Hoarseness, cyano-
sis, paralysis of left recurrent. Infil-
tration of left upper lobe

No heredity. For about 6 months
increasing debility, loss of flesh,
stomach trouble. During last few
weeks fever, headaches, dizziness.
Cachexia, choked discs, ataxia. Small
area of dulness to left of manubrium
sterni

No heredity. For 2 years varying
symptoms. Dyspnoea, cough, some
pain in chest. No fever. Small dull
area to right of sternum gradually
extending over greater portion of right
chest

No heredity. For 6 months cough
with expectoration, loss of strength
and weight, increasing dyspnoea. Slight
fever; physical signs of profuse bron-
chitis over both lungs. Enlarged
glands in right supraclavicular fossa

Father probably died of cancer.
For 3 months pain in left chest. Cough,
increasing loss of flesh and strength,
slight fever. Dulness over left lower
lobe. Attempt was made to remove
left lower lobe by operation. Increas-
ing cachexia; steady fever. General
carcinosis of left pleura

Well until 6 weeks before death;
then slight cough, scant sputum,
paralysis of left recurrent. Pneumonia
of left lower lobe. Clinical diagnosis:
anexxrism or mediastinal tumor

Always well. Little cough, no pain,
some persistent hoarseness. Without
premonition 2 sudden and profuse
haemoptyses causing death in 2 days
Clinical diagnosis: pulmonary phthisis

CARCINOMA

197

Scant, mu-
coid

Purulent

Often
bloody,
profuse

Mucopuru-
lent,
later
bloody

Bloody

Scant,
never
bloody

None

AUTOPSY NOTES

area of upper lobe. Sero- axillary, and
sanguinolent effusion in left clavicular
pleura lymph

nodes

Carcinoma of left main Both lower
bronchus lobes

Carcinoma of main bron- Bronchial
chus of left upper lobe infil- lymph
trating nearly all of upper nodes and
lobe cerebellum

Bronchial carcinoma infil- Both lungs
trating right middle lobe

Carcinoma of right large Lung, bron
bronchus infiltrating middle chial, and
and part of upper lobe. Nu- supraclavic-
merous bronchial and peri- ular glands
bronchial nodules through
out other lobes

Left lower lobe almost en- Pleura,
tirely removed; remnant pericar
cancerous. Carcinosis of dium, heart,
left pleura ; carcinomatous left kidney,
pericarditis. Old tubercu- left adrenal
losis right apex

Ulcerated medullary car- Lymph
cinoma of left main bron- nodes at
chus. Compression of tra- root of left
chea; numerous bronchiec- lung
tatic cavities in left upper
lobe. Aspiration pneumo-
nia of left lower lobe.
Hsemorrhagic effusion in left
chest. Compression of left
recurrent

Carcinomatous ulceration Large ves-
of right main bronchus. sels and
Erosion of branch of right nerves, left
pulmonary artery. Cancer- auricle and
ous infiltration in walls of pericardium
large vessels and nerves,
proliferates through pulmo-
nary vein into left auricle
and into pericardium

METASTASES

MICROSCOPE

No details

Cylindrical
celled carci-
noma

Homy pave-
ment celled
cancer

198

TABLE I

243

244

245

246

247

248

Log. git.

Loc. CIT.

Papinio, Pennato,
Riv. Ven. di Scienza
Med. Anno X, Tomo
XIX, p. 393, Nov.
1893

Carcinoma primitive del
Polmone

Parow,

Diss. Greifswald, 1896
Ein Fall von primarem

LungencarcLnom

Passow,

Diss. Berlin, 1893
(After Paessler)

Zur Differentialdiagno-
se der Lungentumo-
ren insbesondere der
primaren Lungen-
krebse

Peacock,

London Path. Soc.

IV, 1849-50
Primary Cancer of the

Lung

LUNG IN-
VOLVED

CLI1«CAL SYMPTOMS

Apoplexy with paresis of right
facial, _ hypoglossal, arm, and leg.
Cachexia. Respiration normal but
diffuse dry rales with some pleuritic
friction. Clinical diagnosis: general
paresis. Duration about 5 months

No heredity. Syphilitic symptoms
for many years. For a few days pain
in left chest, cough, and dyspnoea.
Flatness with feeble inspiration and
absence of vocal fremitus on left chest.
Intense dyspncea and cyanosis. Aspi-
ration: clear serum; sudden death at
end of aspiration. Clinical diagnosis:
pleurisy and lues

111 6 months before admission with
pain in right chest, sweats, attacks of
cough without expectoration; prostra-
tion. On admission pale, emaciated
child, right chest larger than left;
impaired respiratory motion of right
side. Upper right intercostal spaces
obliterated. Enlarged gland in right
axilla. Absolute dulness over whole
anterior of right chest, also laterally
and posteriorly except for a small
space along spine at apex which gave
a little resonance. Heart displaced
toward left; nothing essential in left
lung. No fever. 150 c.c. blood from
pleural cavity. Second exploratory
puncture only a few drops of blood.
Dyspncea; cyanosis. Death after 3
weeks in hospital

No heredity. Indefinite symptoms
for some time. Later dyspnoea, ca-
chexia, dysphagia. Tumor in right
supraclavicular region

No clinical details

Pain in chest, difScult breathing,
cough, cachexia. Complete dulness
over upper left chest, feeble inspiration
and prolonged expiration suggesting
compression of bronchus. Later in-
tense dyspnoea, cyanosis, swelling of
face, neck, chest, and arms. Swelling
of glands on each side of neck. Entire
left lung impervious to air. Duration
of illness about 10 weeks

CARCINOMA

199

AUTOPSY NOTES

METASTASES

MICROSCOPE

No details

None

No details

None

Carcinoma of main bron-
chus of left lower lobe

Almost complete com-
pression of left lung; sub-
pleural carcinoma of left
upper lobe

Nearly entire right chest
occupied by spheroid mass,
soft and semi-fluctuating.
Upper lobe of lung pressed
upward and backward. Two
lower lobes replaced by neo-
plasm. All other organs
normal

Carcinoma right main
bronchus and beginning of
left. Bronchiectases and
atelectases right upper lobe.
Large nodiile compresses
CESophagus

Carcinoma involving
bronchi and lung and pene
trating anterior wall of chest

Tumor right upper ster-
num and external end left
clavicle in connection with
masses of carcinoma imbed-
ded in upper part left lung
and extending along bron-
chus to bifurcation and
down posterior mediasti-
num. In lung, divisions of
bronchus almost obliterated;
branches of pulmonary ar-

Lower lobe
right lung,
liver, and
many in
brain

Miliary
cancer nod-
ules in
pleura and
middle and
upper right
lobes. No
other meta-
stases

None ex-
cept gland
in right
axilla

Cylindrical
celled carci-
noma

Cervical
and supra-
clavicvQar
lymph
nodes

Medias-
tinum and
supraclavic-
ular lymph
nodes

No further
details

Probably
carcinoma

Cylindrical
and polymor-
phous epithe-
lial cells

Cylindrical
cells

Author mentions as
origin surface epithe-
lium of bronchi

No details

200

TABLE I

249

Pearson, Chas. L.

Charlotte Med. Jour.

XV, 1899, p. 633 •
Case of Encephaloid

Carcinoma of Lung

with Tuberculosis

250

Pbnsttti, v.

Lavori dei Cong, di
Med. Intern. Nono
Cong. Ten. in Torino,
neir Ottobre 1898
(Roma, 1899), p. 338

251

262

Pbpbbb,

Centralbl. f. Path
Anat. Vol. XV, 1904,
p. 948

Pbbitz,

.. Diss. Berlin, 1896
Uber Brusthohlen
geschwiielste

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Grandmother and 2 aunts died of
cancer. Commenced with pain in left
side. Aspiration: clear serum. Pa-
tient worked for 3 weeks, then pain,
cough, fever, and night sweats. Dul-
ness over left chest. Dulness an-
teriorly to nipple; bronchial respira-
tion over apex; absence of breathing
over rest of lung. Heart displaced
to right. Good appetite. Dry cough.
Aspiration negative. Dysphagia later;
haemoptysis. Malignancy suspected.
Duration about 5 months

Always well. Sick since 7 months
before admission when lipoma size of
hen's egg was removed from posterior
right chest. Tumor not examined
microscopically. Three weeks after
admission anterior right chest showed
impaired respiratory motion and a
zone of dulness with bronchial respira-
tion from 2d to 5th rib and from
axilla to margin of sternima. Diag-
nosis of cancer of lung was made.
Patient lost sight of for 4 months, then
great marasmus, paralysis of right vo-
cal cord, pleuritic pain in right side;
no fever. Dulness extended to pos-
terior and lateral wall of thorax.
DyspncEa

No clinical history

Commenced with chill, pain in
right chest, cough, dyspnoea, general
cachexia. Dulness increasing to flat-
ness over entire right chest. _ Di-
minished breathing and fremitus;
stridorous respiration. Paralysis of
recurrent. Appearance of tumor above
sternum. Enlarged axillary and cer-
vical glands. Right radial pulse
smaller than left. Duration of disease
about 5 months

CARCINOMA

201

Prune juice

sputum,
many-
tubercle
bacilli;
pieces of
necrosed
lung
tissue
coughed
up with
haemor-
rhage

Always
"currant
jelly."
No tuber-
cle bacilli,
but on
first ad-
mission
showed
numer-
ous large
flat poly
mor-
phous
cells from
which di-
agnosis
was made

No details

tery flattened and com-
pressed ; pulmonary vein ob-
literated. Tumor enclosed
and compressed upon lower
trachea and aorta and prO'
truded into cavity of peri'
cardium. Left innominate
vein obliterated

Left lung solid with nodu-
lated tumor containing cav-
ity

AUTOPSY NOTES

METASTASES

Right lung almost entirely
transformed into hard mass
Left lung normal

Right lung

Glands at
hilus, liver,
kidney,
mesenteric
glands

Bloody effusion in right
pleura. Right lung normal
in shape but ^ normal size,
I grayish and yellowish white
throughout; interstitial tis-
sue much thickened. Bron-
chi normal

Occasion-
ally
bloody,
no tuber
cle bacilli
or tumor
elements

M1CK08C0PE

Encephaloid
carcinoma.
Tubercle ba-
cilli in cavity

Alveolar
structure;
many large
polymorph-
ous epithe-
lial cells simi-
lar to those
found in spu-
tum. Pleura
free

Left lung,
brain,
lymph
nodes at
hilus

Primary carcinoma of
right main bronchus pene-
trating lung without sharp
definition. Bronchiectatic
cavities

Medias-
tinal, mes-
enteric, axil-
lary, cervi-
cal lymph
nodes and
liver

At the autopsy no
connection could be
traced between scar
from lipoma incision
and tumor of the
lung

TjTjical cy-
lindrical
celled carci-
noma. Prob-
able origin
from smallest
bronchioles
and alveoles

Alveolar
structure ; 2
to 3 layers of
smooth cylin-
drical cells

Diagnosis only pos-
sible by microscope
without which the
case would have been
diagnosed as chronic
interstitial pneumo-
nia with acute fibri-
nous pneumonia in
the stage of gray hep-
atization

Supposed origin:
ducts of bronchial
mucous glands

202

TABLE I

253

Log. cit.

254

255

Log. git.

256

257

258

Pehls,

Virchows Arch. Vol

56, p. 437
Zur Casuistik des Lun-

gencarcinoms

Peerone, a.

Arbeiten aus dem
Path. Inatit. in Ber-
Un, 1906

Entwickelung eines
primaren Cancroids
von der Wand einer
tuberculosen Lungen
caverne

Pertjtz,

Diss. Miinchen, 1897
Zur Histogenese des pri

maren Lungencarci-

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Sudden onset with bronchitis, cedcema
of face, increasing dyspnoea, cyanosis,
dilatation of veins, pain in arms and
chest. At the beginning nothing
essential found in lungs, but absolute
flatness over sternum extending to
both sides. Feeble respiration over
all of right chest. Later effusion in
right chest. Heart dislocated to left.
Aspiration: clear serum. Duration
about 4 months

Dyspnoea, pain in left chest, back,
and arm. Bulging of left chest, im-
paired respiratory motion. Flatness
and vaiying areas of dulness over left
chest. Some fever. Aspiration: tur-
bid serum. Later distinct pulsation
and increased fremitus over anterior
left chest. Improvement; patient
gets about. Gradual retraction of
left chest; dulness again appears;
increasing cachexia. Duration about
10 months

No previous illness. Sudden fever,
pain, cough, expectoration. Some im-
provement, then fever and ssrmptoms
of left pleurisy with effusion. Heart
dislocated to right. Aspiration: 500
c.c. bloody serum; needle penetrating
into hard tissue. Later chills; flatten-
ing and afterward bulging of left
chest. Enlargement of supraclavicu-
lar glands. Aspiration: pus. Resec-
tion of rib

Pain, anorexia, chilliness, fever,
dyspnoea, cough. Expansion right
chest; dulness, feeble respiration
above, absence of breathing sounds
below; no fremitus. Liver displaced
downward. Duration about 3 months

No previous illness. Commenced
with pain in left shoulder; disappeared
but returned very severely.^ Bulging,
impaired respiratory motion. Dul-
ness, diminished breathing and crack-
ling rales over left chest. Tumor
above left clavicle. General cachexia.
Duration about one year

No clinical history

CARCINOMA

203

AUTOPSY NOTES

METASTASES

MICKOSCOPE

Occasion-
ally
bloody,
neither
tubercle
bacilli
nor tu-
mor par-
ticles

Mucoid,
no tuber-
cle bacilli;
no blood

Bloody fluid in right
pleura. Tumor nodules in
mucous membrane of right
main bronchus connecting
with large masses surround
ing trachea and extending
into right chest, penetrat-
ing lung and compressing it
Upper cava compressed

Large firm tumor at left
hilus ; polypoid tumor
masses obstructing left
main bronchus. Tumor
penetrates lung along
bronchial ramifications

No others

Alveolar
structure ;
small cylin-
drical cells

Lymph
nodes and
liver

Pavement
epithelium
with tjTjical
cancer nests

Mostly
bloody

Encapsulated empyema
Carcinoma of left lung and
bronchi. Carcinomatous
infiltration of pleura

Bloody

No tubercle
bacilli

No details

Bloody serum in right
pleura. Right main bron-
chus and branches infil-
trated and obstructed by tu-
mor. Cavities with thick
capsules in upper and lower
right lobes

Tubercular cavity at left
apex; wall of cavity pene-
trated by tumor involving
1st and 2d ribs, and 6th and
7th cervical and 1st dorsal
vertebrae. Compression of
axillary nerves and vessels

Cavity in right upper
lobe, walls of which are
formed by firm white tumor.
Tumor extends to right main
bronchus, wall of which is
perforated, one of the per-
forations communicating
with cavity. Tumor pene-
trates into upper cava

Muscles of
chest, liver,
kidneys,
capsule of
spleen

Posterior
mediastinal
lymph
nodes, liver,
ribs, inter-
costal mus-
cles, brain

No others

Alveolar
structure;
pavement
epithelial
cells

Alveolar
structure ;
cancer nests

Tubercular
tissue with
bacilli in wall
of cavity be-
sides typical
cancer pearls.
Bronchi
intact

No other
details

Alveolar
structure; cy-
lindrical and
cuboid cells
with forma-
tion of mu-
cus. Origin
bronchial mu-
cous glands

Supposed origin
from bronchus

204

TABLE I

NO.

AUTHOR

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

259

Loc. CIT.

No clinical history

260

LOC. CIT.

Diagnosis made during life from
expectorated tumor particles

261

PiTINI & MeBCADANTE,

La Reforma Med.
Roma, Vol. Ill, 1902,
p. 710
Carcinoma midollare
primitivo del polmone

SjTjhilis admitted. On admission
cyanosis of face, cedcema of right arm,
forearm, and hand. For about 6
months harassing dry cough, and pain
in right shoulder. Later cough be-
comes moist. Increasing dyspncea,
irregular dulness over greater part of
right chest from above downward;
diminished fremitus; bronchial respi-
ration; many rales. All other organs
healthy. No leucocytosis; red cells
3,500,000. Later swelling of right
thorax and arm, dulness and absence
of voice all over; diminished breathing.
Still later all signs of effusion in pleura.
Diagnosis of solid tumor of lung was
made. Under observation 21 days

262

Pitt,

London Path. Trans.

39, p. 54 (After

Paessler)
Malignant Disease of

Bronchial Glands

No clinical history

263

PUECH,

Montpellier Med. 2
me SSrie, XI, 1888,
July, p. 6
Cancer de la Trach6e et
Tuberculose pulmo-
naire

No heredity. Disease commenced
with severe bronchitis, general weak-
ness, fever, diarrhoea. Tubercular cav-
ity right apex. Duration about 9
months

264

Reinhardt,

Arch, der Heilk. 19,

1878, p. 369
Primarer Lungenkrebs

CEdoema of upper half of body.
Hoarseness, dyspnoea, dysphagia. Di-
lated veins on posterior and anterior
surface of chest. Dulness over right
upper lobe; diminished breathing an-
teriorly; bronchial behind. No rales.
Effusion in right chest. Little cough;
some fever. Erysipelas of chest.
Death. Duration about 5 weeks

CARCINOMA

205

SPUTUM

AUTOPSY NOTES

METASTASES

MICBOSCOPE

HEMAHKS

No details

Left upper lobe almost en-

Regionary

Alveolar

tirely replaced by large nod-

lymph

structure ;

ulated tumor protruding in-

nodes and

polymorph-

to mediastinum. In centre

wall of left

ous epithelial

of tumor a cavity into which

ventricle

ceUs; tumor

bronchus of upper left lobe

injection of

opens. Left upper bron-

lymph ves-

chus infiltrated with tumor

sels

nodules

Tumor par-

Left main bronchus infil-

Bronchial

Carcinoma-

ticles

trated with tumor; lung

and tra-

tous struc-

studded with small tumor

cheal lymph

ture

nodules; larger tumor at

nodes; both

apex left lower lobe

kidneys
brain

Abundant,

Abundant serous effusion

Left lung,

Typical epi-

Nearly all the usual

mucopu-

in pleurae and pericardium.

axillary.

thelioma.

symptoms of pulmo-

rulent.

Left lung studded with

peribron-

Massive new

nary carcinoma ab-

Nothing

larger and smaller tumor

chial lymph

formation of

sent — no character-

charac-

nodules. Upper part right

nodes.

fibrous tissue;

istic bloody sputum.

teristic

lung firmly adherent to

Right sub-

mucoid and

no haemorrhagic exu-

chest wall ; numerous

clavian

colloid degen-

date in pleura; no ca-

smaller nodules throughout

compressed.

eration with-

chexia

lung, but upper lobe one

All other

in the new

large mass of tumor

organs nor-
mal

formed tumor
masses. Car-
cinomatous
structure in
secondary
lymph nodes.
Lung tissue
completely
replaced by_
tumor. Ori-
gin attrib-
uted to alve-
olar epithe-
lium

No details

Carcinoma of right main
bronchus considerably ob-
structing lumen

No details

Profuse

Left lung normal. Tu-

Peribron-

Alveolar

Tumor evidently

haemop-

bercular cavities right lung.

chial lymph

structure ; flat

gave no recognizable

tysis

White tumor in trachea near
bifurcation, extending into
right main bronchus _ and
partially obstructing it

nodes

epithelial
cells

clinical symptoms

None

Wall of right bronchus
penetrated by tumor start-
ing from hilus. Infiltration
of upper lobe along bron-
chial ramifications. Com-
pression of upper cava

Lymph
nodes at bi-
furcation

No details

206

TABLE I

265

266

267

268

269

270

271

272

273

Reinhardt,
Sections Protocol! des
Dresdener Stadt-
krankenhauses, 1885,
No. 83

Log. git.
1858, 232

Log. git.
1861, 108

Log. cit.
1872, 433

Log. cit.
1873, 260

LOC. CIT.

toe. CIT.

RiPLET,

New York Med.
Record, XVIII, 1880,
691
Primary Infiltrating
Medullary Carcinoma
of Lung

RiSPAL,

Toulouse MM. Vol
II, p. 305 (1900)
Cancer primitif du Pou-
mon

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

No clinical history

Increasing debility, cough, pains in
left chest. Dulness and feeble breath-
ing over lower left chest; tympanitic
percussion note over upper portion.
Duration of disease about 5 months

Cough, dyspncBa, pain in back, ver-
tigo, anorexia, and weakness, bulg-
ing of lower right thorax with dulness
and diminished voice and breathing.
Above this area tympanitic percussion
note and bronchial breathing. Dislo-
cation of heart and liver

No heredity. Always weU. Com-
menced with slight cough, pain in
sternal region, weakness, and dyspncsa.
Dulness from left clavicle downward
with loss of fremitus and distant bron-
chial breathing. Exploratory punc-
ture: small quantity bloody serum
without relief of dyspncsa. Duration
about 4 months

No heredity. Bronchitis since in-
fancy; cough and expectoration al-
ways. For 3 months severe pain in
right chest; anorexia, cachexia. Dul-
ness at right base with diminished
vesicular murmur. Only other symp-

CARCINOMA

207

No details

Mucoid

Purulent
and

bloody,
one

haemop-
tysis

Mucous

Abundant,
yellowish
purulent

AUTOPSY NOTES

Large tumor in left lower
lobe, softened in centre. Ob
struction of main bronchus

Tumor of left hilus.
Bronchiectatic cavity lower
lobe; also nodule in left
lower lobe

Bloody fluid in right
pleura. Large round tumor
in middle lobe involving up-
per and lower lobes. Bron-
chi run freely through tu-
mor; rest of lung com-
pressed. Tumor extends to
heart and compresses upper
cava and pulmonary vein

Large cavity in left lower
lobe surrounded by wall of
tumor with papillary excres-
cences proliferating into in-
terior of cavity

Primary carcinoma of
main bronchus of left lower
lobe. Carcinomatous infil
tration of the lobe. Effu-
sion in left pleura

Solid tumor at hilus of left
lung occluding bronchus and
compressing large vessels

Entire right lower lobe
converted into a large sac
filled with pus and com-
municating with main bron-
chus. Walls of the sac con-
sist of tumor. Walls of
bronchus infiltrated with
tumor and obstructed

Bloody serum in left
pleura. Almost entire left
lung solidified. Right lung
also infiltrated

Large tumor in lower lobe
Softened in spots. Chalky
tubercles in left lung

METASTASES

Brain

No details

Bronchial
and tracheal
lymph
nodes

Liver, peri
toneum, tra^
cheal lymph
nodes

Bronchial
lymph
nodes.
Both kid-
neys

Pleura,
heart, peri-
bronchial,
tracheal,
and medi-
astinal

MICROSCOPE

No details

Medullary
carcinoma

Thick, fi ,
brous matrix
bounding
cavities filled
with epithe-
lioid cells.

208

TABLE I

274 Rosenthal,

.. Diss. Miinchen, 1899
Uber einen Fall von
primarem Lungen-
carcinom

275 ROTHMAN, C.

Deutsch. Med. Wo-
chenschr. 1893, No.
35, p. 844
Primares Lungencar-
cinom (Demonstra-
tion)

276 ROTTMANN,

Diss. Wiirzburg,
1898
Uber primares Lungen-
carcinom

277

278

Log. git.

Rowan, John,

Transact. Ophthal.
Soc. of United King-
dom, Vol. XIX, 1899,
p. 103

lung in-
volved

CLINICAL SYMPTOMS

toms digestive disturbances, consti-
pation, and polyxiria

No heredity. Gradual hemiplegia
of right side with aphasia, convulsions,
and other cerebral symptoms. Later
some dyspnoea. Nothing found on
lungs. Later bronchitis with fever and
cough; symptoms of vocal paralysis.
Duration about 6 months. Entire
clinical picture dominated by cerebral
symptoms; no lung s5miptoins except
cough and dyspnoea

Slight haemoptysis at 17. A year
before admission bloody expectoration,
but nothing could be found in heart
or _ lungs. Good appetite; gained
weight. Later dyspnoea, cedcEma of
face and right arm, dilated veins of
chest. Dulness and diminished respi-
ration over right apex. Haemorrhages
almost without interruption for f of
year. Sudden death from oedoema of
glottis. Probable tumor diagnosed
during life. Duration of disease a
little more than a year

No heredity. Pain, dulness, dimin-
ished breathing and voice sounds.
Exploratory puncture negative. Sud-
den paralysis of both lower extremities.
Fever, dyspnoea, death in collapse

Cough, anorexia, emaciation. Physi-
cal examination of lungs practically
negative

Pulmonary affection _ for 4 months
before admission. Initial haemoptysis;
cough. Impaired respiratory motion
of right chest. Dulness behind to _6th
dorsal vertebra; diminished breathing.

CARCINOMA

209

SPUTUM

AUTOPSY NOTES

METASTASES

MIGROSCOPE

BEMABKS

lymph

mainly poly-

nodes

hedral; many
necrotic or
undergoing
fatty degener-
ation. Peri-
pheral zone of
tumor shows
alveolar
stroma infil-
trated with
small round
cells; alveolar
spaces con-
tain polymor-
phous cells

Mucoid

Carcinoma of left main

Brain, bron-

Alveolar

Origin from epithe-

bronchus perforating wall

chial, and

structure

leum of bronchial

and extending into left lung.

tracheal

well devel-

mucous membrane

Compression and thrombo-

lymph

oped stroma;

sis of right pulmonary ar-

nodes, wall

typical cylin-

tery

of left ven-
tricle of
heart

drical cells
with some de-
generation in
centres of cell
nests

Bloody, no

Infiltrating carcinoma of

Pericardium

No details

tubercle

right upper lobe

bacilli;

profuse

hsemop-

tysis for

almost f

year

Occasion-

A large tumor and con-

Bronchial

Transition

Origin probably

ally

nected with it a smaller one

lymph

from cylin-

from bronchial mu-

bloody

in left lung. Large tumor

nodes and

drical to

cous glands

contains cavity filled with

bodies of

pavement

tumor material and pus.

7th and 8th

epithelium

Tumor proliferation into

vertebrae.

can be dem-

pulmonary vein and left

compressing

onstrated

auricle

cord

Purulent

Emphysema and purulent
bronchitis. Large tumor in
left lower lobe and another
between upper and lower
lobes

Right lung

Pavement
and poly-
morphous
epithelium
and abundant
elastic fibres
in stroma

Bloody, no

Left lung normal. Pecu-

Bronchial

Irregular

Author believes

tubercle

liar fibrous induration along

glands and

cells arranged

origin to be from

bacilli.

bronchi of right lung extend-

left eye. No

somewhat in

glandular or mucous

Many

ing through to left lower

other metas-

form of glan-

structure of bronchi

fatty

lobe and adherent to peri-

tases

dular acini

210

TABLE I

279

280

281

282

283

Metastatic Carcinoma
of the Choroid from a
Primary Carcinoma
of the Lung

Rubinstein,

Wratsch. 1898, No.

32. Centralbl. f.

path. Anat. Vol. X,

1899, p. 240
Zur Frage iiber die

Histogenese des pri-

maren Lungenkrebses

Sabolodnow,
Gesellschaft der
Aerzte an der Univer-
sit. Kasan. Die Med.
Woche, Berlin, 1902,
p. 457

Ein Fall von primarem
Lungencarcinom

Sadowski,

Centralbl. f. Grenz-

geb. 1900, p. 781 _
Beitrage zur Casuistik

der Neubildungen der

Bronchien

Sard, J. H. et Oulie, A.
Toulouse Med. 1901,
2 s. Vol. Ill, p. 109

Un Cas de Cancer pri-
mitif du Poumon

SCHAPER,

Vir chows Arch. Vol.
.. 129, 1892, p. 61
Uber eine Metastase
eines primaren Lun-
genkrebses

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

DuU tympanitic sound all over right
chest in front. No dyspnoea. Cervical
glands enlarged over both clavicles. No
pain. No history of lues. Details of
examination of left eye are given. Di-
agnosis of malignant disease of the lung
made during life. Sudden death about
3 weeks after admission. Duration of
disease about 5 months

No clinical history

No clinical history except statement
that there was arteriosclerosis and pa-
ralysis of recurrent laryngeal and that
diagnosis of carcinoma of left upper
lobe was made during life

Attack of pleurisy with recovery.
Second attack after 5 months. Aspi-
ration 300 c. c. bloody serum ; later pus.
Resection of rib showed tumor

Admitted in semicomatose condi-
tion. Slightest touch painful, hence
only very superficial examination could
be made. Some dyspncea. Heart
feeble. Numerous enlarged glands in
carotid notches and in subclavicular
region. At level of right parotid a
hard painless tumor; skin movable
over it. Patient died next morning

Admitted with apoplexy. Dulness
of entire posterior left lung, also over
considerable part anterior portion left
chest. No other clinical data

CARCINOMA

211

SPUTUM

AUTOPST NOTES

METASTASES

MICHOSCOPE

BEMARKH

granular

cardium. Bronchi consider-

Cancer infil-

cells.

ably narrowed

trates mucous

Haemop-

membrane of

tysis

bronchi and
surrounding
lung tissue

No details

Carcinoma of left hilus

No details

Alveolar
structure ;
cuboid, pave-
inent, and cy-
lindrical cells;
pearls also
found

' Author considers
tumor of alveolar ori-
gin

No details

Left pleura closely adher-

Bronchial

Very thick

Author believes al-

ent. Both upper and lower

glands

fibrous

veolar epithelium to

left lobes uniformly enlarged

stroma sur-

be origin of tumor

and lung tissue replaced by

rounding

small soft white nodules,

small cavities

confluent or separated by fi-

of the size of

brous tissue

pulmonary al-
veoles. These
are filled with
cuboid, cy-
lindrical and
polygonal
epithelioid
ceUs. The
cells are ar-
ranged in a
somewhat
papillary
form over
strands of fi-
brous tissue

None

Carcinoma of right bron-

None men-

Carcinoma

chus with abscesses in right

tioned

keratodes

lung

None

Entire upper lobe of right

Parotid

Simply

lung converted into a block

glands

stated :

of grayish lardaceous tissue

tumor was

without a trace of pulmo-

epithelioma

nary structure. All other

of lung

organs entirely normal, even

those of mediastinum. The

parotid tumor is only a mass

of hypertrophied glands

No details

Large tumor starting from

Bronchial

Alveolar

root of left lung proliferat-

lymph

structure;

ing into lung tissue along

nodes and

irregular

bronchial ramifications

myoma of
uterus

polymor-
phous epithe-
lial cells

212

TABLE I

284

285

286

287

288

289

290

SCHLERETH,

Diss. Kiel, 1888
(After Passler)
Zwei Falle von prima-
rem Lungenkrebs

Log. cit.

Schmidt,

Diss. Jena, 1899
Zur Casuistik des pri-

maren Lungenkrebses

Log. cit.

SCHNOBB,

Diss. Erlangen, 1891
(After Passler)
Fall von primarem
Lungenkrebs

SCHOTTELIXJS,

Diss. Wiirzburg, 1874
Ein Fall von primarem
Lungenkrebs

ScHREiBER, Andreas,
.. Diss. Munchen, 1906
tJber einen Fall von
primarem Gallert-
carcinom der Lunge
mit Metastasen im
Gehim

Not

stated

LUNG IN-
VOLVED

Uncer-
tain

CLINICAL SYMPTOMS

No clinical history-

No clinical history

No heredity. Cough, pain, dysp-
noea, cyanosis. Enlarged cervical
glands. Dulness with diminished fre-
mitus, impaired respiratory motion,
feeble bronchial breathing. Two tap-
pings bloody serum. Sudden death.
Duration of disease about 16 months

No heredity. Cough, dyspnoea, pain.
Dulness over left chest; diminished or
absent breathing. Heart dislocated to
right. Cachexia. Aspiration: bloody
serum containing characteristic tumor
cells. Sudden death. Duration of dis-
ease about 6 months

No clinical history

Disease commenced with cough and
pain in chest. Clinical diagnosis:
pleurisy. Sick for 9 months; then
purely cerebral symptoms — headache,
projectile vomiting, paralysis of left
side, strabismus. No fever; no cough;
no signs on lungs except slight dulness
over left apex. Clinical diagnosis:
tuberculosis of right cerebral hemi-
sphere

CARCINOMA

213

SPUTUM

AUTOPSY NOTES

METASTASES

MICEOSCOPE

REMARKS

No details

In both lungs and pul-
monary pleurae, numerous
nodules of all sizes down to
miliary. Bronchial walls
not involved

No details

Alveolar
structure ;
mostly cylin-
drical cells;
somie flat

No details

Irregularly defined tumor
in right lower lobe extending
from root through lung to
pulmonary pleura

No details

Cylindrical
cells

Bloody, no

Nodulated tumor contain-

Right lung.

No details

Left lung had 3

tubercle

ing cavity in left middle and

both pleurse.

lobes

bacilli

lower lobe. Bronchial walls
infiltrated with tumor

bronchial
and portal
lymph
nodes, gas-

tro-hepatic

ligament.

and right

kidney

No details

Tumor at root of lung fol-
lowing ramifications of
bronchi. Bronchiectases.
Thrombosis of pulmonary
artery

Liver, kid-
neys, right
suprarenal

No details

Tumor along ramifications
of bronchi involving almost
entire right lung, also pleura
and pericardium

Left lung,
cervical and
axillary
lymph
nodes

No details

Clear serum in right

Substernal,

Lymphangi-

The miliary nod-

chest; bloody serum in peri-

tracheal and

tis carcino-

ules throughout lung

cardium. Entire right lung

bronchial

matodes

and pleura are ar-

firm, without air and stud-

lymph

ranged in an anasto-

ded with numerous nodules

nodes.

mosing reticulum

up to size of walnut

Pleura, peri-
cardium,
beginning of
aorta and
pulmonary
artery
studded
with miliary
nodules

corresponding to the
lymphatics. Author
attempts to establish
origin of tumor from
endothelium of lym-
phatics

None

Tumor left lower lobe

Brain, both

Gelatinous

Author assigns

adrenals.

gland-like tu-

origin to alveolar

left kidney,

bules con-

epithelivmi

both ovaries

taining much
mucoid ma-
terial. Bron-
chial epithe-
lium and
bronchial mu-
cous glands
normal. Me-
tastases same
structure

214

TABLE I

291

292

293

294
295

296

297

298

Schroder, Hugo,
Diss. Kiel, 1902

Ein Fall von primarem
Krebs der Lunge

SCHWALB, HeINRICH,

Diss. Wiirzburg, 1894
Ein Fall von primarem
Lungencarcinom

Schweninger,

Annalen des Stad.
Krankenhauses in
Miinchen, 1876-77.
Vol. II, 367

Loc. CIT.

Sehrt,

Diss. Leipzig, 1904
Beitrage zur Kenntniss

des primaren Lun

gencarcinoma

Loc. CIT.

SlEGEL,

Diss. Miinchen, 1887
(After Passler)
Zur Kenntniss des Pflas
terepithelkrebses der
Lungen

LUNG IN-
VOLVED

Both

(?)

62
66

Probably
L

CLINICAL SYMPTOMS

Pneumonia with incomplete absorp-
tion. Thereafter occasional fever;
gradual development of cedoema in ter-
ritory of upper cava. Cough, cyanosis,
dyspnoea. Ronchi over both lungs, but
nothing characteristic. Later ascites,
enlarged liver, albuminuria, and hya-
line casts. Clinical diagnosis: myocar-
ditis after pneumonia. Death from
erysipelas and peritonitis. Duration
of disease about 15 months

Always well. For a few months
dyspnoea, cough, sense of suffocation.
On admission great emaciation; some
cyanosis and fever. Pneumonia of left
lower lobe; bronchitis. Death after
2 days

No clinical history except that pa-
tient was sick for 2 years with symp-
toms of chronic pulmonary phthisis

No clinical history
No clinical history

Clinical diagnosis' pleuro-pneumo-

nia

Intense dyspnoea. Dulness over en-
tire left chest with harsh respiration
and rales. Death from profuse and
sudden haemorrhage. Clinical diagno-
sis: phthisis

No clinical history

CARCINOMA

215

SPUTUM

AUTOPST NOTES

METASTASES

MICROSCOPE

REMARKS

Mucoid

Chronic induration of

None

Hsemor-

No clinical symp-

both lungs. Pneumonic

rhagic areas.

toms pointing to tu-

consolidation of right lower

typical carci-

mor; diagnosis only

lobe ; pleurisy on left. Hasm-

noma prob-

possible with micro-

orrhagic areas in both lungs

ably from

scope at autopsy

diagnosed macroscopically

bronchial epi-

as infarctions, but micro-

theUum and

scopically proved to be typi-

extending

cal carcinoma

along lymph
channels

Profuse

Turbid serum in left
pleura. Tumor size of an
apple in left lower lobe, sur-
rounded by inflamed lung
tissue. Tumor is whitish
gray, sharply defined against
surrounding lung tissue.
Firm fibrous masses inter-
spersed with soft, very cellu-
lar portions of tissue

No details

Alveolar
structure

No details

Tumor nodules in both
lungs

No details

Carcinom-
atous struc-
ture; cylindri-
cal and poly-
morphous
cells

No details

Primary cancerous tumor
of left upper lobe

No details

Carcinoma of right main

Bronchial

Alveolar

bronchus and of cavity at

and tracheal

structure;

hilus of right lung with ero-

lymph

pavement

sion of pulmonary artery

nodes

epithelium.

and acute lethal haemor-

cancer pearls;

rhage. Bronchiectases. Ex-

patches of ne-

tensive chronic ulcerative

crosis

tuberculosis

No details

Bloody fluid in pleura.

Both lungs.

Horny pave-

Carcinoma of right lung

left ventri-

ment epithe-

with gangrenous cavity and

cle, left adre-

lium

chronic indurative pneu-

nal, and 6th

monia. Carcinomatous

rib

thrombosis of pulmonary

artery

Hsemopty-

Carcinoma of left main

Bronchial

Pavement

sis

bronchus with extension to
left pleura, bronchial Ijonph
nodes, and large branch of
pulmonary artery. Chronic
ulcerative tuberculosis of
left upper lobe

lymph
nodes and
oesophagus

epithelium

No details

Large tumor in left upper

Both lungs

Large polyg-

and lower lobes

and left
pleura

onal cells

216

TABLE I

299

300

301

302

303

304

305

Loc. CIT.

SlEGEHT,

Virchows Arch.
1893, 134
Zur Histogenese des pri-
maren Lungenkrebses

Singer,

Prag. med. Woch.

1885, pp. 329-341
Drei Falle von intra-

thoracischem Tumor

Singer,

Diss. Berlin, 1908
Zur Klinik der Lungen-

carcinome

Loc. CIT.

SiROTINI,

Wratsch. St. Peters-
burg, 1905, Vol. 72, p.
58. Lubarsch-Oster-
tag,1907,Ht. 2,p. 734
Two Cases of Primary
Cancer of Lung

Not

stated

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

No clinical history

Admitted 5 days before death suf-
fering from hemiplegia of right side,
aphasia and pleurisy with hsemor-
rhagic effusion in left side

Sudden onset with dyspnoea, cough,
and increasing debility. Later dila-
tation superficial veins. Dulness at
right apex with bronchial respiration
in front; no breathing sounds pos-
teriorly. Pain; harassing cough. Du-
ration about 3 months

No heredity. Previous history neg-
ative, but had lung trouble for some
years. Cough, dyspnoea on exertion.
On admission _ emaciation, intense
dyspnoea, cyanosis; no fever; no glands.
Greater portion of left lung in front
and behind, flat; diminished voice and
breathing. Nothing on right lung.
Aspiration: 1200 c.c. turbid serum.
Paralysis of left vocal cord. Death
in 2 days

No heredity ; no previous illness. Re-
cently weakness, pain in chest. Dulness
and bronchial respiration upper left
apex. No rales. Right lung and heart
normal. Gradually some fever; fine
crackling in left base. Sudden death

Admitted in moribund condition.
Intense dyspnoea for some time, cyano-
sis, hoarseness, some fever. No ca-
chexia. Tumor size of small fist
emerges above sternum. Death within
24 hours after admission

No clinical history

CARCINOMA

217

SPUTUM

AUTOPSY NOTES

METASTASES

MICHOSCOPE

REMARKS

No details

Tumor in right middle

Bronchial

Large polyg-

lobe

lymph
nodes,
pleura,
liver, left
suprarenal,
thyroid, and
both kid-
neys

onal cells

No details

Extensive infiltrating car-
cinoma of left lung and bron-
chi simulating pneumonic
consolidation. No pro-
nounced tumor or nodules.
Extensive secondary carci-
nosis of lymphatics

None

Alveolar
structure; cy-
lindrical cells
with transi-
tion to pave-
ment epithe-
lium

Foul,

Cavity with hsemorrhagic

Pleura,

No details

Origin from bron-

bloody

contents in right upper lobe.
Walls consist of partially
necrotic and infiltrating tu-
mor. Ulcerated medullary
tumor in right main bron-
chus and its larger branches,
obstructing lumen. Ob-
struction of upper cava

liver, adre-
nals and thy-
roid

chial mucous glands

Glairy

Carcinomatous thrombo-

Pleura, peri-

Pavement

sis of left lower pulmonary

cardium.

cell carci-

vein. Carcinoma of left

bronchial

noma

main bronchus infiltrating

and perito-

and occupying the bronchus

neal lymph

of left lower lobe. Diffuse

nodes, left

carcinomatous infiltration of

kidney, left

left lower lobe. Carcinoma-

adrenal, left

tous infiltration of lymphat-

ovary and

ics of bronchi of left upper

in thyroid

lobe

Scant,

Primary carcinoma of

No details

mucopu-

lower left lobe originating

rulent,

from bronchial mucous

no tuber-

membrane. Many small

cle bacUli

pneumonic abscesses

No details

Right upper lobe adher-

Pericar-

Pavement

ent to sternum and to ribs,

dium, right

cell carci-

infiltrated with hard carci-

pleura, ster-

noma

noma. Small bronchi and

num and

bronchioles filled with detri-

upper ribs,

tus and carcinomatous ma-

mediastinal

terial; also some in upper

lymph

cava. Lymph channels in-

nodes

filtrated

No details

Multiple miliary carci-

No details

Flat epithe-

Origin supposed

noma of lower lobe

lial cells

from alveolar epithe-
lium

218

TABLE I

306

307

308

309

310

311

312

313

314

Log. cit.

Smith-Shand,

British Med. Jour
1875, I, 844; II, 41

Stieb

.. Diss. Giessen, 1900

Uber das Plattenepi-

thelcarcinom der

Bronchien

Loc. CIT.

Stilling,

Virchow's Arch. Vol
LXXXIII, 1881, p.

.. 77

ijber primaren Krebs
der Bronchien und
des Lungenparen
chyms

Loc. CIT.

Stobeh,

Amer. Jour. Med
Sciences XXI, 46,
1851

SEX

AGE

LUNG IN-
VOLVED

Not

stated

CLINICAL SYMPTOMS

Diagnosed during life

Cough, pain, hoarseness, right hemi-
plegia. Dulness over left chest; im-
paired respiratory motion; absence of
breathing sounds

_ No clinical history except patient
died of cirrhosis of liver

Cough, pain, infiltration of right
apex, increasing debility. Duration of
disease 6 to 8 months

No clinical history

Cough, dyspnoea. Dulness of lower
f right chest and absence of breathing

CARCINOMA

219

No details

Scant,
bloody

No details

Moderate,
mucoid,
no tuber-
cle bacilli

No details

Tenacious
mucoid

AUTOPSY NOTES

METASTASES

Primary carcinoma of
walnut size in right lung

Left main bronchus
plugged by tumor. Left
lung full of soft tumor ad-
herent to pericardium and
surrounding structures at
root. Compression of left
vagus and recurrent

Submucous carcinoma in
bronchus of left lower lobe
infiltrating surrounding lung
tissue

Primary carcinoma at bi
furcation of right main bron
chus. Gray hepatization of
right upper and middle lobes

Large tumor of bronchus
of right middle lobe extend-
ing into right main bron-
chus, penetrating wall and
infiltrating peribronchial tis

Bloody serum in right
pleura. Polypoid tumor
right main bronchus and in
upper bronchus. Tumor
nodules in both lungs and
in trachea. Bronchiectases
right upper lobe.

Left main bronchus com-
pletely destroyed by tumor
mass in left upper lobe pene-
trating into lower

Upper and middle lobes
almost entirely converted
into tumor infiltrating along
blood vessels and bronchi

Encephaloid mass occu-
pies more than J of right
lung. Contains small cav
ities; tumor in right pri-

No details

Brain

Small poly-
morphous
epithelial cells
almost Uke
sarcoma cells

No details

Regionary
lymph
nodes

Both lungs
supra clavic-
ular lymph
nodes

Bronchial,
mediastinal
lymph
nodes ; also
cervical
nodes, peri-
cardium,
and liver

Bronchial,
cervical, and
retroperito-
neal lymph
nodes; liver
and small
curvature of
stomach

Left bron
chial lymph
nodes

Bronchial,
cervical, and
axillary
lymph
nodes; left
lung, liver,
and left su-
prarenal

Bronchial
and tracheal
lymph

nodes

MICROSCOPE

Origin bronchial
mucous membrane

Although no micro-
scopic examination is
given, there is little
doubt that this tumor
is carcinoma

Horny pave-
ment epithe-
lium

Alveolar
structure ;
horny pave-
ment epithe-
lium

Plexiform
and alveolar
cancer nests;
cancerous in-
jection of
lymph spaces
and prolifer
ation along
vascular and
nerve sheaths

Same as
above

No details

220

TABLE

NO.

ATJTHOB

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Carcinoma of Right

Lung with Symptoms

of Hydrothorax

315

Stumpf,

Diss. Giessen, 1891

(After Passler)
Zur Casuistik des pri-

maren Lungencarci-

noms

Not

stated

No clinical history

316

Suckling,

Lancet. 1884, 1047
Case of Primary En-

cephaloid Growth of

Lung

No heredity; no pain. Dyspnoea,
cachexia. Right chest more volumi-
nous than left. Dulness over lower
right lobe with impaired respiratory
mobility and absence of fremitus.
Later on signs of cavity. Enlarged
Liver. First puncture: bloody fluid;
second negative

317

SZELAG0W3KI,

Thhse de Paris, 1900
Contribution a I'etude
clinique du Cancer
primitif pleuro-pul-
monaire

No heredity; no serious illness.
Commenced with loss of appetite, then
some general stiffness and malaise; ver-
tigo. Later attacks of suffocation. On
admission intense dyspnoea, some cyan-
osis, bulging of left chest ; absolute flat-
ness behind to spine of scapula and in
front to below clavicle ; absence of voice
and breathing. Heart displaced to
right of sternum. Right lung normal.
Aspiration: 1000 c.c; pink fluid; slight
relief. Repeated puncture only small
quantity fluid and but little relief. X-
rays show a lobulated mass to left of
vertebral column besides shadow over
aU of lower left lung. Intense pain and
dyspnoea; dysphagia, fever, delirium.
Duration of disease about 6 months

318

Tillman,

Diss. Halle, 1889

(After Passler)
Drei Falle von prima-

rem Lungencarcinom

No cUnical history

319

Log. git.

No clinical history

320

Log. git.

Not
stated

No clinical history

CARCINOMA

221

No details

Profuse,
whitish ;
later
"currant
jelly"
haemop-
tysis.
Tubercle
bacilli

Scant; no
tubercle
bacilli

No details

AUTOPSY NOTES

mary bronchus,
gans normal

Other or-

Tumor of right upper lobe
proliferating along bron-
chial ramifications into sur-
rounding tissue. At root,
tumor extends into main
bronchus and penetrates in
to lumen. Proliferation of
tumor into pleura, pericar
dium, right auricle, and large
vessels especially upper cava
and right pulmonary artery

Tubercular cavity and
miliary tubercles through-
out right lung. In lower
right lobe a large patch of
yellowish tumor

Left pleura thickened.
Nearly whole of left lung oc
cupied by grayish white tu-
mor softened and degener-
ated in parts

Tumor in right lower lobe
close to large bronchial
branch

Bronchial carcinoma of
lower lobe following bron-
chial ramifications. Nu-
merous small secondary-
nodules each surrounding
small bronchus

Primary medullary nod-
ule in lung. Numerous sec-
ondary nodules in brain,
cerebellum, and medulla.
Nodules frequently show
cystic degeneration

METASTASES

Regionary
Ijonph
nodes

No details

Only lymph

nodes at lu-
lus

Alveolar
tructure ;
polymorphous
epithelial
cells

No details;
author sim-
ply says "epi-
thelial tu-

None

Bronchial,
mesenteric,
and coeliac
lymph nodes
and liver

Brain, cere-
bellum, and
medulla

MICKOSCOPE

Cylindrical
cuboid and
large poly-
morphous
cells

Carcinoma
with cells re-
sembling nor-
mal alveolar
cells

Cylindrical
cells with ten-
dency to mu-
coid degener-
ation

Large cylin-
drical cells
with mucoid
degeneration

222

TABLE I

321

322

323

TURNBULL & WOETH-
INGTON,

Arch. Path. Inst.
London Hospital, Vol
II, 1908, p. 163
Two Cases of Carci-
noma arising pri-
marily in a Bronchus

Loc. CIT.

V. Fetzbb,

Med. Correspon-
denzbl. des Wiirten-
bergischen arztli-
chen Landes Vereins,
1905, p. 139

Ein vom rechten Bron-
chus ausgehendes
Carcinom der rechten
Lunge

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

About 7 months before admission
on lifting a parcel "something gave
way in his back." Ever since pain in
back and down legs. Sweating and
wasting of legs. Tenderness over left
lumbar spine and both sciatica; no
impairment of sensation. Increasing
nervous symptoms; fever up to 106.
Later 2 pigmented spots on inner sur-
face right chest and several spots on
chest and abdomen. Increasing ema-
ciation and weakness. Albumin in
urine and occasionally a trace of al-
bumose. Nothing is said about physi-
cal examination of lungs

Always healthy until 6 months be-
fore admission, then pain in left shoul-
der and back after lifting heavy weight.
Disappeared for some time, then reap-
peared and persisted with occasional
remissions. Loss of weight, tender-
ness on percussion of dorsal spine;
anaesthesia of 8th left dorsal nerve;
wasting of lower limbs. Remarkable
absence of physical signs. X-rays
show apparently deepened shadow to
the left of upper descending thoracic
aorta and 2 small dark shadows in
lower half of right lung. Diagnosis of
either aneurysm or neoplasm of lumbar
spine was made. Later on symptoms
pointing to lungs. Nothing said of
cough, sputum, or physical signs on
lungs. Symptoms mainly referableto
spine — severe pains in legs, wasting
of legs, bladder symptoms, inconti-
nence of faeces, etc. Duration about
10 months

Cough, irregular fever; good appe-
tite. Dulnesa at right base; dimin-
ished voice and breathing. Later dul-
ness over left apex with bronchial
respiration. No rales. Patient feels
better and gains steadily in weight;
leaves hospital having gained 5 kilos.
Works at his trade for 4 months when
readmitted with severe dyspnoea, cya-
nosis, and dilated veins about head,
neck, chest, and upper extremities.
Flatness over right chest; bronchial
breathing but no rales. Intercostal
spaces levelled; heart dislocated^ to
left. Enlarged glands above right
clavicle; 2 tumors on left parietal
bone. CEdoema of right arm. Right
pupil dilated. Duration of disease
about one year

CARCINOMA

223

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

BEMARKS

Once a

Carcinoma of bronchus in

Retroperi-

Alveolar

lump of

left lower lobe. On outer

toneal, in-

structure

foul-

surface both lungs many

guinal, cer-

lined with cy-

smelling

hard miliary nodules. In

vical and

lindrical cells.

material

left lower lobe cavity size of

bronchial

some cuboid-

size of

walnut with ragged edges

lymph

al. Main

walnut,

and containing many white

nodes, right

bronchus,

looking

nodules; communicates with

femur, both

bronchioli.

like "her-

bronchi of 3d and 4th order;

iliac bones.

pulmonary

ring roe"

nodular thickening of mu-

lumbo-sacral

arteries and

cous membrane. Atelecta-

vertebrae,

vein and sur-

sis below cavity. Nodules

ribs, and

rounding

in both costal and visceral

sternum.

lung tissue in-

pleura; adhesions and effu-

Nodules in

filtrated by

sion on both sides

both adre-
nals and in
atrophied
liver. Brain
not exam-
ined

tumor

No details

Carcinoma of lower right

7th and 8th

Acinous

In both cases singu-

bronchus. Carcinomatous

dorsal ver-

structure

larly small size of

lymphangitis of pleura of

tebrae press-

with secre-

primary tumor and

both lungs. Bronchitis and

ing on cord;

tion of mucus

selection of bones as

capillary bronchitis of left

7th and 8th

but greater

chief sites of second-

lower lobe. Myocarditis,

left ribs and

part is at3T)i-

ary growth. Absence

acute endocarditis; abscess

8th right

cal

of physical signs

in spleen; septic infarct in

rib. No en-

pointing to lungs in

right kidney. Solid nodule

largement

both cases

at back of right lower lobe

of lymph

communicating with bron-

nodes in

chus

■

chest

Occasional

No details

Case is interesting

haemop-

on account of the

tysis; no

steady gain in weight

tubercle

during his stay in the

baciUi

hospital

224

TABLE I

324

325

326

327

V. SCHHOTTEH, H.

Mitth. der Gesellsch. f.

inn. Med. u. Kinder-

hlk. in Wien, 1907, p.

145
Demonstration eines

Falles von Carcinom

der Bronchien

V. SCHEOTTER, H.

Zeitschr. f. klin. Med.
Vol. 62, 1907, p. 508
Zur Preezisions Diagnose
der Lungentumoren ;
bronchogenes Karzi-
nom mit Glykogen-
bildung ; Bemerkun-
gen zur Histogenese
desselben

328

WaCHSMANN & POLLAK,

New York Med. Rec
ord, Nov. 1904
Three Cases of Primary
Malignant Tumor of
the Lung

Wagner,

Miinch. med. Woch

1903, p. 133
Primares Bronchial-

carcinom

Waldmann, Anton,
Diss. Miinchen, 1902

Ueber primares Carci-
nom des Lungenpa-
renchyma

Not

LUNG IN-
VOLVED

stated

CLINICAL SYMPTOMS

Most severe heemoptyses for 11
months. Perfectly healthy until first
sudden haemorrhage without apparent
cause. Haemorrhage repeats at inter-
vals of 8 to 14 daj's. Must have ex-
pectorated about 8000 c.c. of blood.
Repeated and most careful examina-
tion showed no cause for the bleeding.
Nose, throat, trachea suspected. X-
ray examination showed nothing;
nothing found on lungs. Broncho-
scope found a tumor at bifurcation of
right main bronchus in right lower lobe

No heredity. 5 weeks before ad-
mission cough, pain in chest, loss of
weight. Dilated veins left anterior
chest and abdomen. Right chest lags
in respiration; flatness over right apex
in front from axillary line over left
border of sternum. Absence of breath-
ing upper portion right lung; dimin-
ished in lower. Tumor suspected and
demonstrated by bronchoscope in
main bronchus just above bronchus of
upper lobe. Excision of small piece
in bronchoscope shows pavement epi-
thelium carcinoma. Cells contain gly-
cogen in small round spheres. Patient
feels better for a time and gains in
weight. Later oedcsma of face, intense
cyanosis; death from exhaustion

Cough, pain, emaciation, clubbed
fingers. Dulness over right upper lobe

No clinical details except that there
was normal percussion note and breath-
ing over whole left lung, but that vocal
fremitus was markedly diminished, al-
most abolished, and that at a very
early stage of the disease the clinical
diagnosis of tumor of the lung prob-
ably starting from bronchus could be
made

Emphysema; bronchitis. Gradual
loss of weight ; pain ; swelling in region
of liver. Six months later fever and
dulness over right upper lobe._ Fever
disappears, but dulness remains and
increases. Two months later cerebral
symptoms and tumor perforating skull.
Duration about 9 months. Clinical
diagnosis: primary tumor of lung with
cerebral metastases

CARCINOMA

225

AUTOPSY NOTES

METASTASES

MICHOSCOPE

Severe
repeated
hEemop-
tysis

No details

Often
bloody.
Later
hsemop-
tysis. No
tubercle
bacilli

Carcinoma of right main
bronchus with carcinoma-
tous degeneration of right
upper lobe. Proliferation
into superior cava. Indu-
ration and cheesy tubercular
remnants in right apex. Tu-
mor of lung contained cav-
ity

Profuse,
bloody.
No hee-
moptysis.
Contains
ceUs sug-
gesting
"tumor
cells"

No details

Bloody; no
tubercle
bacilli ;
no tumor
elements

Ulcerated right upper
bronchus; infiltrating tu-
mor following lymph chan-
nels in lung, also in pleura

Proliferating tumor ob-
structing lumen at final di-
vision of left main bronchus

General carcinomatosis of
left upper lobe. Cancerous
pleurisy of both sides

Examination
of small por-
tion removed
by probatory
incision
showed carci-
noma

None except
upper lobe

Left lung,
lymph
nodes of
neck and
chest; liver,
thyroid
gland

Left lung,
anterior
mediasti-
num, and
left lobe of
liver

Liver, both
kidneys,
dura, brain,
bones of
skull

Pavement
epithelium

There was not
much dyspnoea

Carcinoma

Cylindrical
cell carci-
noma

Origin from bron-
chial mucous mem-
brane

Typical
pavement
epithelium

Author assumes al-
veolar epithelium as
origin of tumor

226

TABLE I

329

330

331

332

333

334

335

336

Walshe, W. H.

A Practical Treatise
on Diseases of the
Lung, etc. 4th Ed.
London, 1871

Waters,

Lancet, XIX, 1871

Wechselmann,

Diss. Milnchen, 1882

(After Passler)
Ein Fall von primarem

Lungencarcinom

Weinbergeb,

Zeitsch. f.Heilk.1901,

II, 78
Beitrag zur Klinik der

malignen Lungenge

schwtilste

Log. cit.

Werner,

Diss. Freiberg, 1891
(After Passler)

Das primare Lungen-
carcinom

Log. cit.

West,

Trans. London Path.

Soc. XXXV, 1884,

87-88
Primary Cancer of Root

of Right Lung

Not
stated

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

Exclusively psychic symptoms.
Neither local nor systemic symptoms
pointing to lungs. No cough. Dura-
tion about 8 months

Pain, dyspnoea, cough. Swelling and
cyanosis of face, neck, arms, and chest.
Supraclavicular glands. Dulness over
right chest; bronchial breathing above,
diminished or absent breathing below.
Duration about 2 months

No clinical history

No heredity. Fever; cough. In-
creasing dulness over right apex; to
a less degree over left. Diminished
fremitus; bronchial respiration. Pain,
dysphagia, dilated veins. Enlarged
axillary glands; compression of tra-
chea. Dyspnoea, cedcema of larynx.
CEdoema of face and arms. Cyanosis.
Death after profuse haemoptysis. Du-
ration of disease about one year.
Diagnosis made during life.

No heredity. Pain, cough, dyspnoea,
emaciation. Secondary tumors in vari-
ous parts of body. Dulness, dimin-
ished and absent breathing over most
of right chest. Spleen enlarged. Pu-
rulent effusion in right pleura. Dura-
tion of disease about 10 months

No clinical history

Pain, dyspnoea, loss of strength, ema-
ciation. Impaired respiratory motion
of right chest. Dulness, faint breath-
ing, no vocal fremitus. Left lung nor-
mal. Puncture furnishes 8 ounces
thick pus. Incision and drainage gives
no relief. Cough only at end of disease.
Duration about 4 3 months

CARCINOMA

227

SPUTTTM

AUTOPST NOTES

METASTASES

MICHOSCOPE

BEMABKS

None

Infiltrating encephaloid
cancer throughout right
lower lobe

Left lung
and brain

No details

Frothy;
later hae-
moptysis

Entire right lung con-
verted into scirrhous tumor
with cavities and beginning
suppuration

Mediasti-
nal lymph
nodes

No details

Scirrhous tumor of both
lungs

No details

Pavement
epithelium
proliferating
from periph-
eral portions
into other-
wise normal
pulmonary
alveoles

Mucoid, oc-
casion-
ally

bloody,
haemop-
tysis. No
tubercle
bacilli.
Abun-
dant epi-
thelial
cells

Carcinoma of right upper
lobe beginning in a second-
ary bronchus and involving
main bronchus, trachea, left
main bronchus, upper cava,
both pleurae, 2d and 3d ribs
and intercostal muscles.
Bronchiectasis right middle
lobe

Bronchial
and cervical
lymph
nodes

Fibrous
stroma; cy-
lindrical epi-
thelial cells

Tumor
particles
are
found

Carcinoma of right main
bronchus; abscess and ne-
crosis of right lower lobe

Liver, kid-
ney, mus-
cles, intes-
tines, pari-
etal bone,
brain

Alveolar
structure; cu-
boid epithe-
lial cells

No details

Tumor in right upper lobe

Both lungs,
regionary
lymph
nodes, liver,
spleen, kid-
neys

Small cuboid
cells

No details

Tumor size of walnut in
secondary bronchus and left
lower lobe

Bones

No details

None

Hard mass at root of right
lung following main bron-
chus which it compresses.
Spreads throughout lung
along bronchial ramifica-
tions. Two abscess cavities

Left lung
and liver

Cancer with
well-devel-
oped stroma

228

TABLE I

NO.

337

338

339

340

341

342

343

344

Log. git.

WiEBER,

Diss. Berlin, 1889
Primares Lungencarci-
nom, etc.

WlLLANEN,

Zeitschr. f. Krebs-
forsch. 1905, III, p.
618. Wratsch (Rus-
sian) 1904, No. 44

Zwei Falle von prima-
rem Lungencarcinom

Log. cit.

WiLLEHT,

Diss. Wllrzburg, 1905
Beitrag zur Casuistik
des primaren Lun-
gencarcinoms

WiTHAUEK,

Therapeut. Monats-
hefte, 1899, April, p.
185
Das primare Lungen-
carcinom

Wolf,

Fortschritt. der Med.

XIII, 1895
Der primare Lungen-

krebs

Log. cit.

Not

stated

Not

LUNG IN-
VOLVED

stated

CLINICAL SYMPTOMS

Brother died of cancer of liver.
Cough, rapid emaciation. Physical
signs like preceding case. Enlarged
supraclavicular glands. Diagnosis
made during life. Duration about 10
months

Family history of cancer. Asthma
and bronchitis. Later pain and tvunor
in leg which was amputated. Tumor
found to be carcinoma. Cachexia;
cough. Death from exhaustion

Clinically the symptoms of catarrhal
pneumonia. Cough, dyspnoea, and ca-
chexia

Clinical symptoms those of chronic
consoUdation of the lung. Cough,
dyspnoea, and cachexia

No heredity; always healthy.
Cough, increasing debility. Dulness
over left lung; diminished breathing;
some bronchial respiration. No pain,
dyspnoea, or fever. Later paralysis left
hypoglossal and facial; complete left
hemiplegia

No heredity. Some dry cough, but
complains mainly of stomach. In-
tense hunger, but disgust for food;
occasional vomiting. Flatness, in-
creased resonance, and absence of re-
spiratory sounds over right infracla-
vicular region. Heart sounds are heard
with especial loudness over this area.
Dyspnoea, pain over both lungs, harass-
ing cough, emaciation. Slight bulging
of dull area

The cUnical picture is that of chronic
phthisis. Nothing to indicate tumor

Clinical history that of chronic
phthisis

CARCINOMA

229

SPUTUM

AUTOPSY NOTES

METASTASES

MICEOSCOPE

BEMABKS

Occasion-

Around main bronchus a

Tracheal

Scirrhus

ally

white firm tumor penetrat-

and cervical

bloody

ing lung following bronchi.
Consolidation and ulcerated
cavity at root of lung

lymph
nodes; liver
and both
kidneys

No details

Tumor size of walnut in

Lung, liver.

No details

Author considers

middle of right lower lobe.

bronchial

the lung tumor the

Tumor infiltration through-

lymph

primary one

out lower lobe surrounded

nodes. Left

by broncho-pneumonic con-

leg

sohdation

No details

Miliary cancer nodules
originating from smaller
bronchioles and alveoli

No details

A well-defined tumor

No details

Occasion-

Bloody effusion in left

Mediasti-

Gland-like

Author calls tumor

ally

pleura. Large tumor in left

nal, perigas-

arrangement;

carcinoma myxomat-

bloody.

upper lobe; somewhat small-

tric and peri-

principally

odes. Origin prob-

Repeated

er one in left lower lobe.

aortic lymph

cyhndrical

ably bronchial mu-

hsemop-

WaUs of bronchi and blood

nodes. Liver,

epithelial

cous glands

tyses

vessels infiltrated. Mucoid

brain, kid-

cells chang-

areas in tumor

neys, right
adrenal and
thyroid

ing to cuboid
and some fiat
polymor-
phous forms.
Distinct se-
cretion of
mucus

No details

Large tumor in right up-
per lobe

Both lungs,
liver, and
kidneys

No details

Tubercular cavity in left

Right

Pavement

lung in which carcinomatous

pleura and

epithelium

tumor proliferates

left inter-
costal
muscles

with typical
cancer pearls

No details

Tubercular cavity in right
upper lobe containing poly-
poid cancerous excrescence
near the efferent bronchus
of the cavity. Walls of

No details

Pavement
epithelium
with cancer
pearls

230

TABLE I

LUNG IN-
VOLVED

345

Log. cit.

346

Log. git.

347

Log. git

348

Log. cit.

349

Log. git.

350

Log. cit.

No heredity. Emphysema, bronchi-
tis, emaciation. Pleurisy and pneu-
monia of right lung; after which dul-
ness remains. Pain; increasing dysp-

Signs of pulmonary phthisis. Heart
pushed to left. Sudden death from
hgemorrhage

CLINICAL SYMPTOMS

No clinical history

Pain in right chest; cough. Dul-
ness over upper portion right chest;
feeble respiration. Increasing emacia-
tion. Left lung normal. Duration
about 2 months

Cough, dyspnoea; dulness over right
chest with diminished respiration. Re-
peated aspirations: clear serum

No heredity. Pleurisy and pneu-
monia; then dyspnoea, night-sweats,
and great cachexia. Left chest more
expanded than right. Flatness with
slight tympanitic note from left clavi-
cle downward; bronchial respiration.
Exploratory puncture negative, but
needle penetrates into hard mass.
Axillary and infraclavicular glands
enlarged

CARCINOMA

231

BPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMARKS

bronchus thickened and mu-

cous membrane ulcerated.

Tubercular granulations all

over neoplasm

Mucoid;

Middle and lower lobe

Liver

Fibrous

later

converted into large tumor

stroma; alve-

bloody.

penetrating diaphragm and

olar struc-

No tu-

continuous with secondary

ture; flat epi-

bercle

tumor in liver

thelial cells.

bacilli or

Epithelial

tumor

pearls in aci-

cells

nous alveoles

Haemor-

Tumor in left apex. In

No details

rhage

left upper lobe large cavity
with necrotic walls; left
main bronchus almost com-
pletely destroyed by tumor.
Tumor surrounds necrotic
walls of cavity. Miliary tu-
bercles over right pleura

No details

Tumor in right lower lobe

Bronchial

Alveolar

penetrating between 7th and

lymph

structure;

8th ribs. Cavity in centre

nodes

small oval

of tumor surrounded by nod-

epithelial

ulated neoplasm. Cavity

cells

communicates with lower

main bronchus, the walls

of which are partially de-

stroyed by tumor

Yellow, no

Prominent tumor of right

Both

Alveolar

Histogenesis not to

tubercle

upper lobe perforating into

lungs

structure;

be determined

bacilli,

right upper bronchus with

pleura, peri-

small oval or

some

destruction of its walls. The

cardium,

cylindrical

blood

cancer is surrounded by
Fresh miliary tubercles.
Both suprarenals are tuber-
cular; tubercular ulcer in
ileum

liver

cells

Scant, no

Small hard nodules at root

Bronchial

Large alveoli

Histogenesis not to

blood or

of right lung. Polypoid ex-

and tracheal

filled with

be determined

tubercle

crescences on mucous mem-

lymph

polymor-

bacilli

brane of larger bronchi. Bi-

nodes.

phous small

furcation surrounded by

Pericardium

epithelial

large tumors of bronchial

cells. Miliary

and tracheal nodes. Fresh

cancer

miliary tuberculosis of both

throughout

[ungs

both lungs

Slightly

Irregularly defined, hard

Pericar-

Alveolar

bloody,

tumor in left lung. Cheesy

dium, left

structure;

but con-

pneumonia in left upper lobe

auricle, left

round and cu-

tains

ilso several tumor nodules.

ventricle

boid epithe-

neither

tubercle

bacilli

Tubercular pleuritis

and lung

lial cells

nor tu-

mor par-

tides

232

TABLE I

351

352

353

364

355

356

357

358

359

Log. cit.

Wolf,
Loc. cit.

LOC. CIT.

Loc. CIT.

Loo. CIT.

Loc. CIT.

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Clinical picture donunated by cer-
ebral symptoms

No heredity. Paralysis of left arm
and leg. Painful swelling of nose and
epistaxis. Dyspnoea and emaciation.
Impaired motility of right chest. Flat-
ness right apex; diilness below. Bron-
chial respiration. Heart displaced to
right

Clinical picture dominated by brain

symptoms

Symptoms of cavity in right chest

Pain in right_ chest, dyspnoea, dry
cough, emaciation. Dulness over
right chest; bronchial breathing. En-
larged, painful liver; ascites. Some
fever

Anorexia, debility, emaciation. Flat-
ness over left chest ; diminished breath-
ing; absence of voice. Duration about
6 months

Sudden onset with chill and pain in
right chest. Dulness; friction at right
base; fever. Later pericarditis. In-
creasing dyspnoea; death. Duration
about 5 weeks

No heredity. Acute onset with
pleurisy. After that emaciation and
cachexia. Loss of patellar reflexes;
left pupil larger than right. Friction
over right lung. Duration of disease
about 3 months

No heredity. Commenced with ano-
rexia and emaciation followed by
symptoms of right pulmonary phthi-
sis; death after a few months without
characteristic symptoms

CARCINOMA

233

No details

Glairy,
shortly
before
death
bloody,
no tuber-
cle bacilli

No details

No tubercle
bacilli

No details

Mucopuru-
lent, no
tubercle
bacilli ; no
blood

Rusty

No details

AUTOPSY NOTES

Ulcerated right main
bronchus leading into large
tumor at the root adherent
to bronchial nodes. Trachea
compressed ; bronchiectatic
dilatations

Retraction of entire right
lung; dislocation of heart.
Right main bronchus almost
completely filled with cauli-
flower-like tumor. Smaller
bronchi of lower and middle
lobes, same tumor. Tmnor
penetrates into right pul-
monary vein and prolifer-
ates into left auricle. Pneu-
monia left lower lobe

Ulceration of right main
bronchus; tumors in right
upper and lower lobes; latter
contains cavity perforating
into pleural cavity

Circular obstructing can-
cer in left main bronchus ex
tending to lower lobe. Cav-
ity in tumor

Right main bronchus
filled with cancer proliferat-
ing from its walls, extending
into trachea. Tumor nod-
ules in right lung

Hard carcinoma of main
bronchus completely ob-
structing it; left lung re-
tracted. Bloody serum in
abdomen; miliary tubercles
in liver

Right lower lobe and part
of middle lobe destroyed by
medullary cancer; right low-
er lobe adherent to pericar-
dium

Carcinoma of lower
branch of right main bron-
chus

Carcinoma of right main
bronchus; bronchiectases in
both lungs

METASTASES

Bronchial
lymph
nodes; brain

Left lung,
dura mater,
tip of nose,
nasal sep-
tum; right
supraclavic-
ular lymph
nodes

Tracheal
and bron-
chial lymph
nodes, brain,
spleen, kid-
neys

Bronchial
lymph
nodes and
liver

Right
pleura, in-
tercostal
inuscles and
ribs, verte-
brae, liver,
dura mater

Miliary car-
cinosis of
peritoneum

Lower cava,
right auri-
cle; liver

Lung,
spleen, liver,
right pleura,
muscles of
back, brain

Right kid-
ney, liver;
spleen

MICROSCOPE

Pavement
epithelium

Adeno-carci-
noma

Alveolar
structure ;
large poly-
morphous
and cylindri-
cal cells

Alveolar
structure; cy-
lindrical cells

Alveolar
structure ;
polymor-
phous cells

Cylindrical

cells

No details

Bronchial mucous
glands normal

Histogenesis not to
be determined

Origin from bron-
chial mucous glands

234

TABLE I

360

361

Loc, CIT.

Wolf,
Loc. cit.

362

363

364

365

366

LUNG IN-
VOLVED

Loc. CTT.

Log. cit.

Loc. CIT.

Loc. cit.

367

Log. cit.

Both

clinical symptoms

Pleuritic eflfusion in left chest. As-
piration: pus. Resection of 9th left
rib with removal of 2000 c.c. of thick
putrid pus. Death

Aspiration of clear serum from right
pleura; dulness not affected. Abscess
over 8th rib opened and rib resected.
Death after a few weeks

Cough, emaciation, bronchitis. Red-
ness and swelling left side of neck;
fluctuating retropharyngeal swelling

No clinical history except died of
suffocation on day of admission

Pain, emaciation. Complete dul-
ness left lung; no voice or breathing
sounds A fluctuating swelling at
angle of left scapula found on incision
to be tumor penetrating from interior
of chest. No cough

Clinically characteristic of pulmo-
nary phthisis

No heredity. Dyspnoea, dysphagia,
emaciation. Pain in left arm. Upper
left chest bulging. Flatness and ab-
sence of breathing over left upper lobe

No heredity. Well until 3 weeks
before admission; then increasing

CARCINOMA

235

AUTOPSY NOTES

METASTASES

No details

Mucopuru-
lent

No details

None

No details

Carcinoma of left main
bronchus and its ramiiica-
tions. Large cavity in left
lower lobe. Extensive
cheesy broncho-pneumonia
of right lung

Right main bronchus
completely filled with papil-
lary growths firmly adherent
to its walls. Tumor pene-
trates into right lung form-
ing a large tumor in upper
and lower lobes. Large ves-
sels compressed ; upper cava
perforated and filled with tu-
mor

Cavity in right upper lobe
communicating with bron-
chi completely closed by tu
mor originating from their
walls

Pericar-
dium, Uver,
left kidney,
and right
suprarenal

Mediasti-
nal lymph
nodes; left
auricle, kid-
neys, left
suprarenal

MICROSCOPE

Pavement
epitheUum re-
sembling epi-
dermis

Left kid- Pavement
ney, 3d cer-; epithelium
vical verte-
bra with de-
struction of
bone and
compression
of cord; also
left ventri-
cle and bron-
chial Ijonph
nodes

Papillary proliferation Both lungs,
almost completely closing liver, spleen,
lower portion of trachea andjand left

extending into both bronchi.
Also large tumor surround-
ing trachea and large bron-
chi and compressing upper
cava

Entire lower lobe con-
verted into large cavity the
walls of which consist of
white tumor. Main lower
bronchus communicates di-
rectly with cavity and is
obstructed by proliferating
tumor

Tumor proliferation in
right main bronchus; bron
chiectatic cavities in right
lower lobe

Left main bronchus al-
most completely filled with
tumor which proliferates
from its walls and extends
along ramifications into left
upper lobe forming large
hard, white tumor

Carcinoma of left main
bronchus and left lung

kidney

Bronchial
lymph
nodes and
lung

Bronchial
lymph
nodes and
liver

Bronchial

and retro-
peritoneal
lymph
nodes; peri-
cardium

No details

REMARKS

Pavement
epithelium

Alveolar
structure;

236

TABLE I

368

369

370

371

372

373

Log. cit.

Log. git.

Wolf,
Loc. cit.

Log. cit.

Loc. CIT.

LTJNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

hoarseness, pain in chest, dyspnoea,
dysphagia, and palpitation. Paralysis
of left recurrent. No signs in heart
or lungs. Treated for 6 months by
electricity and felt well; then rapid
failing, dyspnoea, effusion in left pleura

Father died of cancer of the stomach.
Well until a year ago, then dyspnoea,
debility, and emaciation. Left upper
chest retracted and impaired respira-
tory motion. Dulness over left lung
with loud bronchial breathing

No clinical history

Always well. Disease commenced
with paralysis of right vocal cord and
dysphagia. Soon thereafter dyspnoea
and a sense of suffocation. Later
intense tracheal stenosis. Hard nod-
ules in thyroid which seem to extend
up from below sternum. Dulness
over sternum and on right side behind.
Tracheotomy, with long canula intro-
duced into right bronchus. This ia
followed by putrid bronchitis, im-
paired deglutition, increasing debility.
Double pleuro-pneumonia; death

Sudden onset with anorexia, debility,
pain in lower abdomen, emaciation,
icterus, cedcema of skin of abdomen and
lower extremities. Liver much en-
larged; no nodules can be felt.
Nothing found in lungs. Duration
of disease only about 3 weeks

Clinical symptoms of pleurisy with
effusion

No heredity. Well until 6 months
before admission when dyspnoea, pain
in chest, cough. On admission cyano-
sis, impaired respiratory motion of
left chest. Dulness from middle of

CARCINOMA

237

Bloody, no
tubercle
bacilli or
tumor
cells

No details

Haemopty-
sis; tuber-
cle bacilli

AUTOPSY NOTES

Left main bronchus com-
pletely obstructed by carci-
noma proliferating also into
trachea and right bronchus.
Greater part of lung con-
verted into solid tumor
extending along bronchial
ramifications

Carcinoma of right main
bronchus

METASTASES

Just below right lobe of
thyroid a large tumor which
penetrates into right upper
chest adherent to bones
which are not affected. Lob
ulated tumor from bifurca
tion extending into right
main bronchus, penetrating
its walls, and extending into
surrounding lung tissue.
Tumor in upper lobe in di
rect contact with large tu
mor on thyroid

Left main bronchus and
bronchus from left upper
lobe obstructed by cancer
Walls of both bronchi infil-
trated

Obstruction of right main
bronchus by cancer. Sur-
face of right lung covered
with net of lymphatics in-
jected with white tumor ma-
terial

Carcinoma growing from
walls of both bronchi and
trachea and obstructing
their lumen. Continuous
with this a tumor spreading

Bronchial
lymph
nodes, peri-
cardium,
heart, thy-
roid, and
both supra-
renals

Bronchial
Ijonph
nodes, right
lung, liver,
lymph nodes
around por-
tal vein,
retroperi-
toneal nodes
and bodies
of 7th to
10th dorsal
vertebrae

Bronchial
lymph
nodes

MICROSCOPE

Bronchial
lymph
nodes and
liver

Bronchial
lymph
nodes, right
pleura, peri
cardium

Left auri-
cle; oesopha-
gus and left
kidney

pavement
epithelium
typical giant
cells

Scirrhus-
like; small
round and
cuboid cells

Alveolar
structure ;
broad con-
nective tissue
bands of stro-
ma; large and
oval epithelial
cells

No details

Origin from bron-
chial mucous glands

Origin probably
from bronchial mi
cous glands

238

TABLE I

NO.

AUTHOB

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

374

Z1EM88EN,

Berlin, klin. Wochen-
Bchr. 1887

scapula downwards; no fremitus.
Dulness over right apex with feeble
respiration and rales. _ Aspiration
evacuated large quantities of clear
serum. Death with symptoms of
progressive tuberculosis

Diagnosed first as tuberculosis; then
as syphihs. Dulness over entire left
anterior chest extending to lateral and
posterior aspects to below spine of
scapula. Over this area bronchial
breathing and dry rales. Bulging of
left chest; intercostal spaces obliter-
ated. All symptoms and signs dis-
appeared under antisjT)hilitic treat-
ment; then reappeared; again shght
improvement under mercury followed
by rapid failure and death

CARCINO^IA

239

AtTTOPST NOTES

At first fi-
brinous,
then
rusty

over both lungs and into left
auricle. Pulmonary veins
compressed. Lesions of old
and more recent phthisis

Jellj'-like mass at apex of
left lung: remainder of left
lung diffusely infiltrated
with carcinoma. Large ab-
scess behind sternum; an-
other behind pericardium

METASTASES

None

MICROSCOPE

Carcinom-
atous struc-
ture

240

TABLE II

Barclay, H. C.

New Zealand Med.

Jour.,V, 1892, 170-172
Sarcoma of Lung

Bauman & Bainbridge

Lancet, 1903, I
Primary Sarcoma of the

Lung

Bell,

Monthly Jour. Med
Science, London, 1846

-47

Bjornsten,

Centralbl. f. Path.

Anat., Vol. 15, 1904,
.. p. 513
Uber Lungen und Herz

geschwiilste bei Kin

dern (Swedish)

Blumenthal,

Diss. Berlin, 1881
Zwei Falle von prima-

ren malignen Lungen

tumoren

Bock, A. F.

Weekly Med. Review,

St. Louis, Vol. XIX,

1889, p. 512
Primary Sarcoma of the

Lung

3 yrs.
11 mos,

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

No heredity. Disease commenced
with pain at right base, some cough,
slight temperature. Dulness over
greater portion of left chest; absence
of vocal fremitus, some harsh respira-
tion and diminished breathing sounds.
Emaciation. Temperature at times
to 104. Gradually bulging over left
chest; oedcema of left arm and chest.
Glands above left clavicle. Two ex-
ploratory punctures practically nega-
tive. Pain always at right base

Well until 6 weeks before admission.
Illness commenced with headache and
abdominal pain; later emaciation,
cough, haemoptysis. Flatness, dimin-
ished voice and breathing, bulging of
intercostal spaces, displacement of
heart to right. Fever 101. Aspira-
tion recovered only a small amount
of bloody fluid without anything char-
acteristic. Duration 8 weeks

Pain in sternum ; later severe cough,
dyspncea, and vomiting. Retraction
of left chest; imperfect expansion, no
fremitus. Dulness over entire left
lung in front and behind; absence of
breathing sounds; numerous rales.
CEdoema of upper and lower extremi-
ties; diarrhoea. Duration of disease
about 3 years

No clinical history

For several years pain in left arm;
7 months before admission swelling
on left chest; later swelling in left
axilla reaching size of a child's head.
No respiratory disturbances. Dulness
over left chest more in front than be-
hind, with absence of breathing sounds.
No cough; no sputum. _ Fluctuation
in axillary tumor. Aspiration with-
draws a Hght green, clear, mucoid fluid

No heredity. Disease commenced
with fever and severe pain in left side,
the latter continuing until death.
Fever yielded to quinine (probably
malarial). No cough; some dyspnoea.
Sweating of right half of body; left
always dry. Left thorax larger than
right. Impaired respiratory motion;
enlarged superficial veins. Marked

SARCOMA

241

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMABKS

Scant,
bloody

Old and recent pleuritic
adhesions in right chest.
Effusion in left pleura.
Greater part of left lung
replaced by hard, nodular
timior. Smaller bronchi
occluded

None

"Small celled
sarcoma"

Hffimop-

tysia

Upper lobe of left lung re-
placed by soft sarcomatous
tumor. Pleura thickened

None

Abundant,
green and
foetid

Lower left lobe one large
cavity with hard irregular
walls, filled with green fluid.
Numerous spherical nodules
excavated in same manner
scattered through remainder
of left lung and in right

None ex-
cept nodules
mentioned
in right lung

None given

Although no micro-
scopic examination is
given, the age of the
patient, sputum and
character of the nod-
ules speak for sar-
coma

Not given

Entire right lung trans-
formed into soft nodular tu-
mor. Large vessels at heart
surrounded by tumor

Left lung,
pericardium
and heart
muscle

Round celled
sarcoma

None

Left pleura 400 c.c. bloody
fluid. Upper lobe of left
lung compressed and flat-
tened. Of the lower lobe
only a narrow border of
highly compressed lung tis-
sue remains, all the rest
taken up by a large tumor
which has eroded several
ribs, and which has pene-
trated into the axilla and
compressed the brachial
plexus

None

Myxosar-
coma

None

Entire left thorax occu-
pied by white tumor mass
without visible lung struc-
ture. Left bronchus en-
tirely obliterated. All other
organs healthy

None

Large spin-
dle celled sar-
coma

242

TABLE I

NO.

AUTHOB

SEX

AGE

LUNG in-
volved

CLINICAL SYMPTOMS

emaciation. Flatness and absence c

breathing sounds over all of left lung

Heart to right of sternum. Repeate

aspiration only small quantity sere

purulent fluid. Sudden death dvu-in

aspiration. Duration of disease

months

Box, C. R.

St. Thomas Hosp. Re-
ports, 1896, p. 260
Sarcoma of Lung

No heredity; good health until
months before admission, when grac
ually increasing lump under angle c
left scapula. Slight cough, pain, in
creasing dulness over upper left ches
Diminished voice, breathing an
fremitus. Negative aspiration. Late
dilatation of superficial veins ; enlarge
ment of axillary and cervical glands
Later dulness and tubular breathin
over right upper lobe. Occasions
fever. Extreme dyspnoea and cyanosis
Duration of disease about 1 1 months

Bramwell, Byron,
Clinical Studies, Vol.
I, 1903, p. 130

Solid Intrathoracic
Tumor

Illness commenced 7 months befor
admission with dyspnoea on exertioB
weakness, hoarseness, cough, pain i
left chest. Luetic infection admittec
Dulness all over left chest, more fla
on upper part than base. Lou
bronchial breathing at base, increase
vocal fremitus; no rales. Punctur
negative. Left chest i inch more thai
right. Heart not displaced. _ Patien
was treated with KI and improve
somewhat; gained 7J pounds in weigh
Physical signs remain the same. Sue
den death

Braureuteh,

Diss. Miinchen, 1881
(after PoUak)

Prim^res Sarkom der
Lunge und der Bron-
chial driisen

No clinical history. Admitted un
conscious and moribund; died afte
5 days

Chiari,

Wien, 1878, No. 6
(quoted after Fuchs)

Anzeiger der Gesell-
schaft der Arzte

No clinical history except that chil
died of facial erysipelas and genera
oedcema

Coats, Joseph,

Glasgow Med. Jour.,
New Series, Vol. VI,

1874, p. 274

Not me

ntioned

No data except persistent vomitin
and symptoms of laryngeal obstruc
tion

SARCOMA

243

AUTOPSY NOTE8

Nearly the whole of left
lung converted into a soften-
ing tumor continuous with
large external mass. Erosion
of 5th to 8th ribs. Large
hard tumor infiltrating
upper and middle right
lobes, adherent to upper
dorsal vertebrae and infil-
trating dura. Cord healthy
All other viscera healthy

Large new growth from
root of lung and bronchial
glands extends in large
masses along bronchi into
lung. Left main bronchus
completely occluded, the
lung collapsed and airless.
Bronchiectasis in lower lobe.
Arch of the aorta completely
surrounded by tumor

Enormous enlargement of
bronchial glands of right hi-
lus with abscesses. Nearly
half of right lower lobe con-
verted into sarcomatous tu-
rnor proliferations from the
hilus, mostly along bronchial
ramifications

Upper lobe of right lung
hard and firm; middle and
lower lobes compressed. In
lower part right lobe pneu-
monia. Section of upper
lobe could be completed only
with a saw, and showed a
spherical tumor 10 cm. in
diameter. In interior of tu-
mor bronchioles could be
made out

Disease centred in lymph
nodes at root of lung and ex-
tended from there to glands
of neck, many as large as

METASTASES MICK08C0PE

Right
lung, verte-
brae, spinal
dura

Only
bronchial
lymph nodes
mentioned

No details

None

Not men-
tioned

Not given

No details
given; simply
stated sar-
coma

LjTnpho-
sarcoma

Spindle
celled sar-
coma with
calcification

Lympho-
sarcoma

244

TABLE II

A Case of Lympho-sar-
coma of the Bronchial
Glands

Cockle,

Medical Times & Gaz.
Oct. 29, 1881, p. 518

Cohen (S. Solis) &

KiRKBRIDE,

Proceedings of Path.
Soc. of Philadelphia,
New Series, Vol. Ill,
1900, p. 200
Tumor (Sarcoma?) of
the Mediastinal and
Bronchial Glands;
Metastases in Liver.
Rupture with Fatal
Haemorrhage

COLOMIATTI,

Rivista Clinica di Bo'
logna, 1879, Gennaio
Virch. Jahrbuch for
1879, I, p. 267

CURRAN,

Lancet, 1880, II, p.
258

Da VIES, Arthur,

Transactions London

Path. Soc, XL, 1889,

p. 46
Lymphosarcoma of Left

Lung

Not

given

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Dyspnoea. Absolute dulness, ab-
sence of voice and breathing over en-
tire left chest. Heart displaced. La-
ter increasing dyspnoea and diarrhoea;
then coma, convulsions, and death

Pain in lower right chest. Right
pupil larger than left. Nothing said
about cough, sputum, temperature,
etc. Enormously enlarged nodulated
liver, left lobe simulating enlarged
spleen. Right lung expands less than
left. Irregular areas of dulness in
lower chest with diminished breath-
ing and absence of fremitus. Haemo-
globin 60; reds 4,400,000; whites
18,000. Albumin and casts in urine.
Aspiration shows serosanguinolent
fluid with enlarged leucocytes. Slight
dyspnoea, sudden collapse, death

No data

Blow on left chest; later swelling of
that spot and fever. Puncture nega-
tive. Signs of pneumonia over left
apex. Dulness on both sides lower
down. Scarcely any respiratory move-
ment of left chest. Copious haemor-
rhages. Rapid increase of tumor.
Duration of disease about 5 months

Pleurisy a year and three quarters
before admission to hospital. 9 months
before admission cough, gradual loss
of weight, night sweats, dyspnoea,
pain in left chest. Shortly before
admission pain in right groin. Physi-

SARCOMA

245

AUTOPSY NOTES

METASTASES

MICROSCOPE

a hen's egg. Pericardium,
both parietal and visceral
involved. At auricles mus-
cle had been replaced by
tumor which penetrated in
to cavity of auricles, both
right and left. Growth ex-
tended likewise into trachea
bronchi, and lungs. Right
vagus buried in tumor and
its tissue involved

Bloody serum in left pleu- Retro-
ral sac. Upper part left peritoneal
pleura and lung filled with IjTnph
soft tumor. Tumor appar- nodes
ently from hilus along bron
chial ramifications. Left
pulmonary vein obliterated

Abdomen contains 2,000 No others
c.c. of blood and large clots mentioned
from two rents in Hver cap-
sule, which is enormously dis-
tended by layers of swollen
tumor nodules. Anterior
mediastinal glands much en
larged; tracheal and right
bronchial glands also en-
larged. Heart and large
vessels pushed somewhat to
the left. Several small nod
ules in left lung, also in left
bronchial glands. Right
bronchial glands enormously
enlarged; right main lower
bronchus almost occluded by
tumor; this tumor passes
along bronchial ramifica-
tions and infiltrates lower
lobe._ Separate timior nod-
ules in right lung.

Right upper lobe convert- No details
ed into an amber-colored
gelatinous neoplasm

Left lung consisted of a None

mass of what the author
calls "medullary cancer,"
which had eroded 7th to 9th
ribs and penetrated chest
wall

Large tumor above left Liver, ret
clavicle; large mass above roperito-
Poupart's ligament filling up neal lymph-
hollow of ilium to median nodes; over
hne; several nodular masses' spine erod-
below this. Left pleural ling vertebra

Round celled
sarcoma

Unsatis-
factory

Probably lympho-
sarcoma, possibly
from bronchial glands

Spindle
cells and pe-
culiar form of
giant cells

No details

Original not acces-
sible. I. A.

Probably sarcoma

Round celled
lympho-sar-
coma

246

TABLE II

LXJNG IN-
VOLVED

CLINICAL SYMPTOMS

Demange,

Revue Med. de I'Est,

IV, 119

(Quoted by Fuchs)

De Renzi,

Giorn. Internaz. de

See. Med. Napoli,

1885
Sarcoma primario del

Polmone

Dick, J. A.

Australian Med.Gaz.,
Vol. XV, 1896, p. 50

Notes in a Case of
Primary Malignant
Disease of the Lung

Duckworth,

British Med. Jour.,

1885, I, 943
Malignant Disease of

the Lung

Elkan, Julius,
.. Diss. Mlinch., 1903
Uber primare Sar-
kome der Lunge im
Anschluss an einen
Fall von primarem
Sarkom der linken
Lunge

cal signs were those of commencing

phthisis with rapid consolidation with
cavity at left apex. In the course
of 3 weeks cavity disappeared and
complete dulness with loss of voice
and breathing sounds took its place.
Heart pushed to right side. Large
neoplasm appeared in right groin and
eventually smaller growths above left
clavicle. Duration of disease at least
15 months; probably longer

For 5 months increasing debility
and emaciation. Pain in right chest;
dulness over left chest with absence
of breathing. Heart dislocated to
right. Later cedcsma of left chest,
enlargement of liver, dyspnoea and
cough. Exploratory puncture nega-
tive; sudden death

Pain in right chest and hypochon-
drium; headache, epistaxis; swollen
glands in neck

Symptoms of pleurisy with effusion
of right side; 3 months later puffy
swelling of face and neck; slight
cyanosis; dilatation of veins over
right chest; orthopnoea; impairment
of respiratory motion. Absolute dul-
ness over right chest in front and
behind except small area over apex.
Absence of voice and breathing; every-
thing else normal. Death 4 months
after first examination

Incomplete left hemiplegia; cough;
flatness below 4th rib with absence
of voice and breathing. Purulent
fluid in pleura; pain in right chest

For some time cough and bloody
sputum, then swelling of hands and
feet; slight rise of temperature for
weeks; some loss of strength and
dyspnoea. At first examination lungs
found normal except some dry rales
at about 3rd left rib anteriorly.
Systolic murmur at apex of heart.
History of syphilis. Clinical diag-
nosis at that time bronchitis with
myocarditis. Temporary improve-
ment. X-ray showed a dense shadow
over whole of left upper lobe. Supra-
clavicular glands enlarged. Diagnosis
of tumor made principally by X-ray
picture. Duration of disease about
10 months

SARCOMA

247

AUTOPSY NOTES

cavity completely obliter-
ated and the whole left chest
filled with hard new growth;
hardly any lung substance
visible. Neoplasm pene-
trates diaphragm into abdo-
minal cavity. Nothing on
right lung

6 to 8 encapsulated timaors
from the size of a pigeon's
egg to that of a fist in left
lung. No bronchi could be
traced in them. Left main
bronchus completely filled
with tumor. Thrombosis
of pulmonary artery

Round celled sarcoma of
right lung compressing right
bronchus

METASTASES

and involv-
ing pan-
creas; right
iliac bone
and lymph
nodes

None

MICROSCOPE

No details

Clear serum in right No others

pleura. Neoplasm at root
of right lung pressing on
venae cavae and right auricle.
Right lung reduced in size;
neoplasm extending along
bronchial ramifications
throughout right lung.
Growth surrounds right
main bronchus and involves
bronchial glands. Bron-
chiectatic cavity in lung

Neoplasm from root of Various

right lung, proliferating parts of

along bronchial ramifica- brain, liver,

tions and invading right pancreas
lung

Bloody serum in left
pleura. Large encapsu-
lated greenish tumor in left
upper lobe

Nodules
on pleura;
tumor infil-
tration of
2nd, 3rd
and 4th ribs

Fasciculated
sarcoma

Round
celled sar-
coma

Mixed,
round and
spindle
celled
sarcoma

Diagnosis of tumor
made during life.

Author believes tu-
mor to have origi-
nated in lung tissue
itself

Round

celled sar-
coma

Medullary
spindle
celled aar-

248

TABLE II

Faerell,

Maritime Med. News

Halifax, XIII, 1901,

p. 291
Lympho-sarcoma of

Lung

Fbhband,

Sarcoma primitif du
Poiimon gauche
(after Chauvain)

FiNLET,

Medical Times and
Gazette, London,
1885, Vol. I, p. 145
Case of Lympho-sarco-
ma of Left Lung vnth
great displacement of
Heart

LUNG IN-
VOLVED

Not
stated

FOOTE, A. W.

Proceedings Dublin

Path. Soc, Session

1871-2
Primary Encephaloid

Sarcoma of Lung

Fraseb,

Edinburgh Med. Jour
1880 - 1881, XXVI,
677-673

CLINICAL SYMPTOMS

Soldier; complained of pain in neck
and shoulders for 9 to 10 months, also
in left chest. Loss of flesh, short
breath on exertion. On admission
complete flatness over left lung in
front from 4th rib down; absence
of breathing and fremitus. Pos-
teriorly flatness from spine of scapula
down; loss of voice and breathing.
Slight dullness and absence of breath-
ing at right base. Heart displaced
to right. Diagnosis: pleurisy. Aspi-
ration: "dark fluid." Death 6 days
after admission

111 for about a year before admission
to hospital, but nevertheless gives
birth to a normal chUd. Pain in
chest; dulness to about middle of
left lung; abolished breathing ; harass-
ing cough; bulging of chest, respira-
tory immobility ; displacement _ of
heart. No fever, but emaciation.
Enlarged axillary glands. Diagnosis
made during life

No heredity. For 3 years before
admission failing strength and pain
in epigastrium and lower part of
sternum. Cough, emaciation, dysp-
noea. Lies on back and left side and
any attempt to change position brings
on cough and suffocation. Tumor
below clavicle extending towards
axilla; similar smaller mass above
clavicle, and a large irregular mass
from left interspace to breast. Left
chest larger than right and immobile
on respiration. Nearly all of left
chest in front and behind revealed
absence of breathing and absolute flat-
ness. Heart displaced far over to
right. (Edcema of face, left arm, and
chest. Duration about 3i years

Sick for 3 months before going to
hospital. Dyspnoea and a sensation
of weight across chest. Left chest
gave all the signs of pleuritic effusion,
chronic and receding. Slight con-
traction of that side of chest. _ Heart
not displaced. Intense pericardial
friction. No enlarged glands, no
pain, no haemoptysis; much cachexia.
Death from hemiplegia 7 weeks after
admission

Pain in right hip and right shoulder.
Dyspnoea and cough. Effusion in left
pleura. Bronchitis ; dilatation of veins
over left chest. Secondary tumors
around left clavicle and right humerus

SARCOMA

249

AUTOPSY NOTES

METASTASES

MICKOSCOPE

No tubercle
bacilli

Bloody; hae-
moptysis

None

No details

Copious,
often
bloody

Entire left lung except
small portion of apex occu-
pied by large fibrous mass,
involving and adhering to
pericardium and heart and
invading left auricle and
pleura. Right lung normal
except some pleurisy at base

Entire left lung occupied
by tumor

Hard nod-
ule in left
ventricle
and second
ary growth
involving
nearly | of
left auricle.
No other
metastases

None, not
even in
pleura

Simply
stated :
lympho-
sarcoma

Remarkable that
the man performed
his duties as a soldier
until 5 or 6 days be-
fore his death

Spindle celled
sarcoma

Heart and pericardium
firmly adherent. Neoplasm
filling almost entire left
chest. Tumor on surface of
chest communicates directly
with tumor of lung. Bron-
chiectatic cavities and (
eluded bronchi

Bronchial,
mediastinal,
axillary
lymph
nodes, liver

Lympho-
sarcoma

Entire left lung infiltrated
with neoplasm, bounded by
a mass of compressed lung
tissue. Only tube through
mass is pulmonary artery,
which is much compressed;
bronchi and pulmonary
veins not distinguishable

Left lung entirely solid;
large tumor in centre reach-
ing surface at 3rd and 4th
ribs posteriorly

None

Round celled
sarcoma

Bronchial
and cervical
lymph
nodes, left
shoulder,
right hu-
merus, right
hip

Small round
celled sar-
coma

250

TABLE II

FUCHS,

Diss. Miinchen
Beitrage zur Kenntniss
der primaren Ge-
schwulstbildungen in
der Lunge

Log. git.

Hagenbach,

1882
(after Roth)

BLlhbis,

St. Bartholomew's
Hosp. Reports, Vol.
28, 1892, p. 73
Intrathoracic Growths

Loc. CIT.

Log. git.

LUNG IN-
VOLVED

lOJ yrs,

CLINICAL SYMPTOMS

No cUnical history

Marked cachexia; senile bronchitis;
some vomiting after deglutition which
improves. Death without symptoms
pointing to lungs

Clinical symptoms mainly cerebral
and psychic; with the exception of
some emphysema nothing abnormal
found in lungs

Treated for right pleurisy for about
7 weeks; diagnosed later as encap-
sulated empyema of right upper lobe
increasing in extent. Increasing
dyspncea; cyanosis. Absolute flat-
ness over right apex in front to 3rd
rib; behind to angle of scapula. No
fremitus, diminished respiration, sibi-
lant rales. Right cla\'icle protrudes,
as also supraclavicular space, where
there is absolute flatness. 3 proba-
tory punctures in region of flatness
draw blood but no pus. Diagnosis of
tumor of right upper lobe made dur-
ing life

Cough, pain in right shoulder,
dyspnoea. Left chest more promi-
nent; deficient respiratory move-
ment; diminished vocal resonance;
bronchial respiration. Complete flat-
ness of entire left chest extending
over sternum to right. Four tap-
pings without relief. Duration about
6 months

Pain, weakness, cough. Dulnesa
at right apex; impaired resonance
over whole of right chest; diminished
voice and breathing; some rales.
Duration about 4 months

Pain both sides of chest; cough,
slight hsemoptysis. Flatness of left
chest; absence of voice and breath-
ing. Duration about 3 months

Cough, pain in left side, swelUng
of abdomen. Absolute flatness with
absence of voice and breathing over
entire left chest. Duration about
10 months

SARCOMA

251

AUTOPSY NOTES

METASTASES

MICROSCOPE

No details

None

No details

Scant

Scant,
muco-
purulent;
no blood

Scant,
slight hae-
moptysis

Scant, no
hsemop-
tysis

Primary sarcoma with
central softening in right
upper lobe.

Nodulated tumor size of
a child's head enclosed
thick fibrous capsule, in
right lower lobe

Nodule size of a pea in
left upper lobe

Medullary sarcoma of
right upper lobe extending
to ribs and vertebrae. Tu
mor size of child's head dis
places right subclavian art-
ery upward, right bronchus
downward

Bronchial
lymph
nodes, liver,
pancreas

Nodule in
left lower
lobe

None

Pleura

Not given

Spindle
celled sar-
coma

Structure
in some parts
Ismapho-sar-
coma, in
others fibro-
sarcoma

Round celled
sarcoma

Left lung infiltrated by
soft neoplasm involving
bronchial lymph nodes, oeso-
phagus, and destrojdng and
obliterating left main bron-
chus

Upper right lobe com
pletely infiltrated with neo-
plasm, white, firm and solid
in upper portion; soft and
decomposed in lower portion

Upper lobe of left lung
almost entirely occupied by
new growth ; lower lobe com
pletely invaded by tumor

Lower lobe of left lung
completely occupied by
hard, white tumor. Pleura
enormously thickened and
honeycombed

Regionary
lymph
nodes, lung,
pericardium

Small
nodules in
right lung,
no others

Right lung,
bronchial
and medias-
tinal lymph
nodes

Liver,
spleen, pan-
creas, peri-
toneum,
and retro-
peritoneal
glands

Sarcoma

Small round
celled fibro-
sarcoma

Round and
spindle celled
sarcoma with
excessive fi-
brous tissue

Sarcoma

252

TABLE II

Hellendall,

Zeitschr. f . Klin. Med.

XXXVII, 1899, p.

435
Ein Beitrag zur Diag-

nostik der Lungen-

geschwiilste

HiLDEBHAND,

Diss. BerHn, 1887
(after PoUak)
Primares rundzellen
Sarkom der linken
Lunge im Anschluss
a n Lungentuberku-
lose

Hooper,

Intercolonial Med.
Jour, of Australasia,
Vol. Ill, 1898, p. 222

Sarcoma of Lung

Iscovesco,

Bull, de la Soc. Anat

de Paris, 1888, p

182
Sarcome pulmonaire

simulant la Phthisie

JAN38EN,

Diss. Berlin, 1879
Ein Fall von Lungen-
sarkom mit grass-
griinem Auswurf

KOBYLINSKI,

.. Diss. Greifswald, 1904
Uber primare Sar-
kome in der Lunge

Not
stated

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

No heredity; dry cough, dyspnoea;
pain in chest. Increasing dulness
from right apex downward. Varying
physical signs. Later cedcEma of legs
and right arm. Dyspncsa dysphagia,
ascites. Dilated superficial veins.
Large hard liver. Bloody effusion in
right chest. CHnical diagnosis at first
tuberculosis, but examination of white
particles in bloody effusion showed
heaps of round cells from which the
diagnosis of sarcoma of lung was made.
Duration of disease about 6 years

Acute onset with pneumonic symp-
toms; since then emaciation, dizzi-
ness, cough; severe dyspnoea. Dura-
tion of disease about 1 year

No heredity; always well; disease
commences with area of dry pleurisy.
Fever to 102, persistent dry cough;
great debility, dyspnoea. 2700 c.c.
clear serum removed by aspiration
from right chest. Area of dulness
anteriorly over middle of right lung
with normal breathing and voice
sounds. Tumor was diagnosed from
sweating, cough, emaciation. CEdcema
of right face, chest, and arm. Death
from asphyxia. Duration about 6
weeks

No heredity. Pain in right chest;
much cough. Signs of consolidation
of left apex and patient went through
all the clinical stages of phthisis —
night sweats, haemoptysis, some
cedcema of face; slight albuminuria

No heredity. History of lues.
Pain in right chest, dyspnoea, cachexia
Later painful enlargement of inguinal
glands. Attack of pneumonia with
crisis. After this progressive dulness
with friction sounds, some of which
also appeared on left chest. Antisyphi-
litic treatment shows apparent im-
provement; nevertheless dulness in-
creases and cachexia progresses.
Duration a little over 1 year

No heredity. 8 weeks ago attack
of scarlet fever. 2 weeks ago sud-
denly cough, pain in chest. Slight
paralysis first of foot, then ascending.
6 days before admission last volun-

SARCOMA

253

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

EEMABKS

Occasion-

Large tumor in right lung

Only in

Typical

ally

covered with thickened

liver, no

round celled

bloody,

pleura. Lung compressed,

others

sarcoma

contains

in parts cystic

no tuber-

cle bacilli,

several

abundant

hsemop-

tysea

Mucoid,

Pulmonary phthisis. Ex-

Absolutely

Small

numerous

tensive sarcomatous prolif-

none

round celled

tubercle

eration in left main bron-

sarcoma in-

bacilli

chus with ulceration of bron-
chial wall. Large nodular,
hard tumor at left hilus
compressing right and left
main bronchus

vading a
previously
tubercular
lung. Origin
not to be de-
termined

Bloody; no

Right pleural cavity oblit-

None

No details

The rapidity of de-

tumor ele-

erated. Whole right lung

given

velopment in this

ments; no

infiltrated with new growth.

case is remarkable.

tubercle

soft and whitish — "evi-

Hooper had known

bacilli

dently a rapidly growing
round celled sarcoma"

the patient well for
10 years. Death en-
sued in 6 weeks
from time of onset

Scant, hae-

Two large tubercular cav-

Right

Not given

Some doubt as to

moptysis,

ities in right lung; sarcoma-

kidney and

primary site of tu-

nothing

tous nodules in right pleura.

cEBophagus

mor. Possibly pri-

said

Right lower lobe sarcoma-

mary in kidney

about

tous infiltration. Tubercles

tubercle

in left lung

bacilU

Grass green

Right lung filled with con-

Mediastinal

Round

color

necting tumor nodules. Tu-

and bron-

celled sar-

mor in middle of otherwise

chial lymph

coma

normal left lung. Abscess

nodes.

anterior mediastinum over

spleen, pan-

trachea

creas, hilus
of both kid-
neys, retro-
peritoneal,
axillary and
inguinal
lymph nodes

Mucopuru-

Left lung adherent; clear

Spinal cord

Spindle

lent, no

serum in pericardium.

celled sar-

tubercle

Large solid tumor size of a

coma

bacilli.

man's head in left lower lobe

no blood

almost entirely replacing

254

TABLE II

Krienitz, Walter
Diss. HaUe, 1903
Adenoma der Lunge

Keoniq,

Berlin klin. Wochen-

schr., 1887, p. 964
Ein Fall von primarem

Sarkom der rechten

Lunge

Lanqe, J. C.

Penna. Med. Jour.,
Pittsburg, 1903-4,
Vol. XXXIII, p. 202

Four Cases of Malig-
nant Disease of the
Lunga

Loo. CIT.

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

tary urination; 5 days before, last
fascal movement; within last few days
paralysis up to horizontal mammillary
line. No sensation in paralyzed parts;
no oedcBma; no glands. Dulnesa with
absent breathing over greater part of
left chest behind. Some pleuritic
friction; bronchial respiration anteri-
orly. Heart displaced to right. Pro-
batory aspiration some turbid bloody
fluid. Haematuria. Fluid in chest
present only in thin layers; most of
the dulness due to solid mass in lung.
Duration a little more than 1 month

Pain in chest, increasing dyspnoea,
palpitation. Flatness over whole of
left chest. Heart displaced to right

Pain in right chest. Dulness below
right clavicle; diminished voice and
almost absent breathing sounds. Clini-
cal diagnosis of lympho-sarcoma made
from particle of tissue withdrawn by
needle at time of puncture. Later
fever, increasing dulness and disloca-
tion of heart, enlargement of liver;
dyspnoea; swelling of cervical and
mediastinal glands; tremendous sweat-
ing, especially on right side. Duration
of disease about 10 weeks

Progressive loss of strength and gen-
eral malaise without definite symptoms
for some months; then pleuritic pain in
left chest, some fever; violent cough.
Flatness over left lower lobe. Aspira-
tion negative. No glandular enlarge-
ment ; no cedcema. Death from exhaus-
tion 3 months after first clinical signs

No clinical history. Came to hos-
pital with incision in 7th left inter-
costal space in front. Left face, arm,
neck, and chest oedoematous. Dilated
veins; enlarged glands. Flatness over
left chest. Much pain. When flap
including 2 ribs was lifted up a large
sarcoma was revealed

SARCOMA

255

No details

lung tissue. Involves cos-
tal pleura and penetrates in-
tercostal muscles; involves
also lower part upper lobe.
Tumor penetrates through
vertebral column and fills
canal from 4th to 6th verte-
bra. Does not penetrate
dura, but compresses cord.
Above and below compres-
sion extensive softening of
medulla spinalis

Large tumor weighing 20
kilos filling whole of left
chest and extending to right,
pushing heart to axillary
line. Left lung compressed
to small strip between tumor
and chest wall. On section
soft white tumor tissue con-
taining numerous cystic _
cavities and areas of ossify-
ing and ossified tissue

No blood,
no tuber
cle bacilli,
no elastic
fibres

Scant,
mucoid

No details

AUTOPSY NOTES

METASTASES

Large tumor in anterior
mediastinum continuous
with tumor of right lung.
Tumor affects several large
bronchi. In upper right
lobe a fresh pnevunonia

"Encapsulated fibro-sar-
coma in left lower lobe" as
large as a small cocoanut.
Small abscess around tumor

No details

Enormous
masses of fi-
brous tissue
in some pla-
ces having
the charac
ter of soft
medullary
sarcoma.
Areas of hy-
aline carti-
lage. The
small cysts
have a glan-
dular char-
acter, lined
with cylin-
drical cells

Right ax
illary lymph
nodes, liver,
cervical, su-
pra- and in-
fraclavicu-
lar glands
with pres-
sure on vag'
us and sym^
pathetic

None

MICBOSCOPE

Fibro-chon-
dro-adenoma
with sarcoma-
tous degener-
ation

Sarcoma-car-
cinomatodes

No details

256

TABLE II

Lehndohff,

Wiener med.Wochen.

1909, No. 31 & 32
Primares Lungensar-

kom in Kiudesalter

Lenhahtz,

Miinch. Med. Woch.
1896

Primary Sarcoma of
Lung with Metas-
tases in Left Motor
Region

Levit,

Diss. Erlangen, 1901
(after Pollak)

Primares Rundzellen
sarkom der linken
Lunge mit Obtura-
tion von grossen
Bronchien und Bron-
chiectasen

Log. cit.

Mac Donnell,

New York Jour, of

Med.. Sept., 1850,

153-157
Extensive Encephaloid

Disease of Left Lung

Not

stated

(adult)

stated

LTJNQS IN-
VOLVED

CLINICAL STMPTONS

No heredity. Sudden cough and
high fever for about 8 weeks. Bron-
choscopy and pumping out of left
lung; child worse after it. Pain,
dyspnoea, high fever, harassing cough.
Puncture in left axilla, much blood;
2nd puncture in front near sternum,
same result. Some temporary im-
provement. On admission to hos-
pital cyanosis, no fever, left thorax
more voluminous than right, lags in
respiration; flatness over all of left
chest in front and behind to about
7th rib with sharp boundary. Right
lung normal. Notwithstanding the
absolute flatness, respiration much
diminished and some vocal fremitus
is heard all over the flat portion. No
glands; other organs normal. Increas-
ing signs of compression — intense dysp-
noea, cough, cedcema, dilated veins.
No dysphagia. Haemoglobin 65-70;
reds 4,820,000; whites 16,000. Poly-
nuclears 70.4%. X-ray shows tumor
convex boundary at base and
erosion of 6th rib. Another punc-
ture of tumor brings out blood and a
piece of tissue from which the diag-
nosis of round cell sarcoma was made.
Death after about 5 months of sick-
ness

Cerebral symptoms prominent.
Flatness right middle and lower lobes.
Hoemorrhagic fluid in right chest

No clinical history

For 2 years pain in left side and
left shoulder; dyspnoea. Later small
tumor above left clavicle; ptosis of
left eyelid and contraction left pupil.
Dry cough, emaciation, paralysis of
left arm, oedcema left arm and chest,

SARCOMA

257

AUTOPSY NOTES

Left lung entirely com
pressed and pushed down-
ward and backward. Sar-
coma originating from tip of
left lower lobe, compressing
lung and displacing heart
and mediastinum to right.
Tumor is encapsulated and
centre degenerated and ne-
crotic. Erosion of 6th rib

No details

At hilus of left lower lobe
an irregular grayish red nod-
ulated mass. Pleura over
2 c.c. thick, containing nu-
merous abscesses. The tu-
mor is found loosely adher-
ent to the walls of many
smaller and larger bronchi
and bronchiectases

Large soft sarcoma of left
hilus. Numerous nodules
throughout lung. Prolifer-
ation into pulmonary veins,
obstructing them. Tumor
fills and obstructs numerous
bronchi

Nothing left of lung ex-
cept thin layer of lung tissue
at diaphragmatic portion of
tumor

METASTASES

None, not
even re-
gional
glands

No details

Nodules in
right lung,
other organs
healthy

MICROSCOPE

Small
round celled
sarcoma,
probably
congenital

No details

Small
round celled
sarcoma

Round celled
sarcoma

Not given

Origin not to be
determined

258

TABLE II

attended by Unusual
Symptoms

Mac Donnbll,

The Canada Medical
Record. XVI,. No. 1,
1887, p. 3

Gaillards Med. Jour.,
Vol. XLVI, Dec. to
June, 1888, p. 540-
543
Malignant Disease of
the Lung

Maeini,

Giorn. Internaz. della
Scien. Med. Napoli,
1891, XII, 1890. p. 98

Sarcoma primitive del
Polmone

McCall Anderson,
Glasgow Med. Jour.
1893, XXXIX, p. 243

Cilinical Memoranda.
Left Hemiplegia Com
plicating Tumor at
Root of the Lung

Meter,

Diss. Milnchen, 1900
Beitrag zur Casuistik

der primaren Lun-

gensarcome

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

obliteration intercostal spaces, respi-
ratory immobility. Dulness over en-
tire left chest in front and behind
with bronchial respiration. Apex of
heart in right axilla. Dilated veins,
paralysis of right arm; bulging of
intercostal spaces

Shortness of breath for some weeks;
no other symptoms. At first visit
whole right chest flat on percussion,
presenting the physical signs of pleu-
risy with effusion. Repeated punc-
ture negative, except small quantity
of blood at one time containing the
usual number of leucocytes. Gradu-
ally increasing dyspncsa and signs of
thoracic pressure — distension of tho-
racic veins, bulging of right chest,
oedcema of right side of face. Death
after an illness of 6 weeks

Family history of cancer. After a
disease of chest diagnosed as bron-
chitis patient had persistent harassing
cough. After a fall pain in right chest
with cough and fever. Pneumonia is
diagnosed. Since that time not well.
Pain in shoulder and anterior portion
of right chest radiating from above
angle of right scapula. At that time
there was very slight dulness and
slightly diminished breathing. All
other organs normal. Later oedcema
of right hand and arm, increasing
dulness under clavicle and slight
prominence above; entire absence of
voice and breathing over greater part
upper lobe. Gradual bulging of right
chest in region of 3 upper ribs anteri-
orly; no fever; no glands. Increas-
ing dyspnoea; increasing pain. Clini-
cal diagnosis : tumor in chest probably
in lungs. Duration 22 months

No heredity; always in good
health. 2 months before admission
inflammation of lungs. Later complete
left hemiplegia. Clinical diagnosis:
cerebral haemorrhage. Sudden death

No heredity. Emaciation, cough;
symptoms principally brain symptoms.
Dulness over all left lung, bronchial
respiration, diminished motion; fine
rales at both apices. Liver much
enlarged and tender. Icterus. Clini-
cal diagnosis: pneumonia, phthisis
pulmonalis, brain tumor, possibly
old apoplexy. Duration of disease
at least 8 months

SARCOMA

259

SPUTUM

AUTOPSY NOTES

METASTASES

MICEOSCOPE

REMARKS

No details

Right lung adherent to
chest wall and seat of exten-
sive new growth. No other
organs involved

None

Alveolar
structure.
Small round
celled sarcoma
with numer-
ous lymph
elements.
Lympho-
sarcoma

Mucopuru -

Firm, whitish-gray tumor

None

Fibrous

lent, often

occupying right upper lobe.

stroma; cells

bloody

partly broken down and
eroding clavicle and ribs.
No glands

of varying
size and
shape; where
tumor is hard
stroma pre-
dominates,
where it is
soft and med-
ullary, almost
entirely cel-
lular. Author
calls it sar-
coma

No details

Bulky tumor at root of
left lung extending into lung
and centred around main
bronchus, the walls of which
are incorporated in the tu-
mor. Large hsemorrhagic
cavity in right corona
radiata

No details

Small
round celled
sarcoma

Bloody

Large, diffuse, nodulated

Liver,

Alveolar

Origin probably in

tumor left lower lobe desig-

brain, peri-

structure

Ijmiph nodes

nated at autopsy as primary

bronchial

with thick

carcinoma

lymph
nodes

bands of fi-
brous tissue
arranged in
meshes; ex-
tremely fine
reticuli in
meshes, which

260

TABLE II

NO.

AUTHOE

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

MlLIAN ET BeENABD,

Biill. de la Soc. Anat.
de Paris, 1898, p. 336
Sarcome aigu du Pou-
mon; Generalization,
Bacteries dans les tu-
meurs

No heredity; no syphilis. _ 4 months
before admission while in perfect
health, sudden pain and paresis of
both legs. Later an attack of pneu-
monia. Since then cough, dyspnoea,
some congestion and rales at both
bases; cyanosis; high fever; para-
lytic and spine symptoms. Clinical
diagnosis varied; last tuberculosis.
Duration about 4 months

MiiiiAN ET Mante,
Soc. Anat. de Paris,
Vol. 76, 1901, p. 82

Sarcome primitif du
Poxunon

History of syphilis. Admitted for
brain symptoms. One year previ-
ously had severe bronchitis; since
then some cough, dyspnoea, emaciation,
fine rales over both bases. Clinical
diagnosis: syphilitic hemiplegia. Sub-
comatose state; apoplectic attack,
increasing fever. Death about 1 week
after admission

MiRINBSCU ET BaHON-
CEA,

Revue mens, des
Malad. de I'enfance,
Paris, 1894, XII, 82-
86
Sarcome primitif du
Poumon

Uncle died of cancer. 3 months
before admission acute disease, prob-
ably pneumonia. Acute symptoms
improved, but general condition re-
mained bad. On admission flatness
in lower posterior portion of right
chest above and below to spine of
scapula and in right subclavicular
region. Some pleuritic friction at
right base. Spasmodic cough like
whooping cough. Exploratory punc-
ture of thorax negative. All other
organs apparently healthy. Dulness
extends, involving nearly whole of

right lung. Breathing rough and
diminished with amphoric note. Soon
signs of thoracic pressure — cyanosis
of face, cedcema, dilatation of super-
ficial veins of chest, hoarseness, in-
tense attacks of dyspnoea. Death from
suffocation more than a month after
admission to the hospital

Mora,

Not

Both

Toper and formerly mine worker.

Ann. univ. de Med. e

stated

Admitted in moribund condition; no

SARCOMA

261

AUTOPSY NOTES

METASTASES

MICROSCOPE

Green, pro-
fuse hae-
moptysis

No details

Mucus,
bloody at
first.
Nothing
charac-
teristic

Left lung almost entirely
transformed into large cav-
ity, the walls of which are
lined with whitish-gray neo-
plasm; cavity contains white
liquid. Also tumor sur-
rounding 5th and 6th ribs

Irregular tumor near hilus
of left lung; showed some
fluctuation and on incision
seemed composed of a num-
ber of cavities with soft walls
filled with thick, creamy
greenish fluid. In right
lower lobe a solid tumor
size of a large orange, sur-
rounded by a series of cavi-
ties containing a purulent,
viscid, greenish or chocolate
colored fluid, which can in
some places be lifted by the
fingers in strings the size of
a penholder. Atelectatic
lung tissue around the tumor
traversed by whitish bands

Right pleura almost ob-
literated ; slight yellow effu-
sion in left. Right visceral
pleura everywhere studded
with nodules, whitish yellow.
Nearly whole of right lung
occupied by soft pulpy tu-
mors; in the centre a large
cavity formed by degener-
ated tumor and filled with
puriform material. All
other organs healthy

No details

Both lungs from root to
base and more anteriorly

Medias-
tinal and
hilus lymph
nodes;
bodies of
2nd and 3rd
vertebrae
invaded by
tumor ex-
tending into
canal and
compressing
cord

Anterior
mediasti-
num, spleen
In brain a
multitude of
small cavi-
ties filled
with green-
ish or choco-
late colored
pus. All
other organs
healthy

Medias-
tinal and
bronchial
glands

are filled with
small round
cells. Alveolar
round celled
sarcoma

Small
round celled
sarcoma in
part resem-
bling lympho-
sarcoma ;
large round
cells also.
Sarcomatous
lymphangitis

Sarcoma

Round and
spindle celled
sarcoma
originating
from conneC'
tive tissue
of septa and
alveoles

Bronchial

glands

Small
round and

262

TABLE II

Chir., Milan, 1875,
Vol. 231, p. 11-17

Moore,

Lancet, 1890, II. p.
876

Pal, J.

Jahrbuch der Wiener
K.K. Krankenanstalt,
III, 1894. Vienna,
1896, p. 545

Lymphosarkom der
Lunge

Pater et Rivet,
Arch, de med. experi-
mentale et d'anato-
mie path. Vol. XVIII
1906, p. 85

Sur un Cas de Sarcome
primitif du Poumon

Pfrttz

Diss.' Berlin, 1896

LUNG IN-
VOLVED

Both

CLINICAL STMPTONS

history obtainable; could not be
examined. Death from suffocation

Duration 4 months. Signs of pres-
sure on recurrent laryngeal and sym-
pathetic; left pulse absent; some
fever. Constriction of left subclavian

Well until 5 months ago. Suddenly
severe pain in stomach, headaches,
weakness, dizziness, constipation last-
ing 3 or 4 days at a time, but ending
in spontaneous evacuation. Pain in
left chest, legs, and feet; some jaun-
dice; pain all over abdomen. Later
vomiting after almost every meal;
then pain in right chest and about
heart; some dyspnoea. No vomiting
for 3 months, but all other complaints
worse. On admission jaundice, some
cyanosis; dulness from 3rd rib down-
wards, merging into heart dulness;
flatness posteriorly. Diminished frem-
itus and breathing. Dilated veins
over abdomen; Uver enlarged and
tender. Increasing dulness over both
lungs. Systolic murmur; accentua-
ted 2nd sound. Apex beat to left
of mammUlary line. Aspiration of
both pleurEe withdrew bloody serum.
Death 2 days after admission. Noth-
ing said about cough or sputum

Illness commenced with cough and
loss of weight. Gradual swelling of
numerous peripheral Ij'mph nodes.
On admission harassing cough with
dyspncea and cyanosis; hoarseness;
enlarged lymph nodes everywhere.
Paralysis of right vocal cord. Dulness
at left base with rales. Some diar-
rhoea. Rapid decline. Fever. Red
cells 3,174,000; whites 8,370; poly-
nuclears 71%; eosinophiles 0; lym-
phocytes 9; transitionals 17. Clinical
diagnosis: tuberculosis. Duration
about 1 year

Sudden onset with cough, pain in
chest, dyspnoea, night sweats. Ca-
chexia; slight fever. Swelling of
neck, dislocation of larjmx; paralysis
left vocal cord. CEdoema left chest;
dilated veins. Dulness and diminished
respiration over left chest. Aspira-
tion clear serum. Needle enters
hard tumor. Enlarged axillary glands.
Duration of disease about 3 months

S.IRCOMA

263

SPUTUM AUTOPSY NOTES

METASTASES

MICROSCOPE

EEMAEK8

than posteriorly trans-

enlarged; in

spindle celled

formed into soft pinkish tu-

part cheesy

sarcoma.

mor adherent to pleura and

and calcare-

Pigment and

diaphragm. Upper portion

ous

connective

of both lungs interstitial

tissue indu-

fibrosis

ration of rest
of lung

No details

Nearly entire upper por-

Pleura,

Round and

tion of left lung replaced by

right lung,

spindle celled

whitish tumor

mediastinal
and inguinal
lymph nodes

sarcoma

No details

Right lower and middle
lobes replaced by tumor lar-
ger than child s head with
only a trace of compressed
lung tissue remaining at
its peripherj\ The greater
part of the tumor is hard;
some places soft on section
with round pigmented areas
corresponding to bronchial
glands, also here and there
the lumen of a bronchus can
be seen

Both auri-
cles, pericar-
dium; head
of pancreas,
retroperito-
neal lymph
nodes; com-
pression of
lower cava
by tumor

No details

Numerous tumor nodules

_ Medias-

Large

Author claims origin

at both bases; more in left

tinal mesen-

round celled

from intra-alveolar

teric.

sarcoma

tissue at left base.

peripheral

Numerous nodules in

lymph

liver shown to be

nodes;

tubercular, contain-

nodes at

ing bacilli

hilus of

liver

Occasion-

Lympho-sarcoma of left

Bronchial,

Lympho-

ally bloody

lung, bronchi, pleura, and
mediastinum. Bronchiec-
tases, purulent bronchitis,
indurative pneumonia of left
iung; (xdoema of right lung.
Degeneration of left recur-
rent ; myo- and endocarditis

cervical,
axillary
lymph
nodes; left
auricle

sarcoma

264

TABLE II

Log. cit.

PiTOT,

Arch, de Med. et de
Pharm. MU., Vol.. 34,
Paris, 1899, p. 306
Sarcome primitif du
Poumon a Marche
rapide

Poison et Robin,
Gaz. mfed. de Paris,
1856, No. 9 Quoted
(from Fuchs)

Tumor Fibroplastique
du Poumon

PoLACci E La Franca,
Arch. Ital. de Med.
Intern., Palermo,
1901, Vol. IV, fasc.
1-2, p. 408

Enorme Sarcoma primi-
tive del Polmone con
sintomi di pseudo
mixedema

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

No heredity. After some gastric
disturbance anorexia, cough, pain in
chest, night sweats, dyspnoea. Dimin-
ished respiratory motion over right
chest; posteriorly, flatness and dimin-
ished voice and breathing. Aspira-
tion: bloody serum. Tumor appears
over right clavicle. Right chest be-
comes retracted; stridorous respira-
tion; club fingers. Aspirating needle
now enters hard, firm tissue. Dura-
tion about 1 year

Tubercular family history. Always
well. Cough since a month before
admission. Looks well. On both
lungs sonorous and sibilant _ rales.
No dulness anywhere. No lesions in
other organs. Diagnosis: bronchitis
and grippe, which was then epidemic.
No fever. Some weeks later dyspnoea;
slight dulness middle of left lung
behind. Dulness increases towards
apex. Severe pain at left base. Later
pleural effusion, heart displaced to
right; fever. 800 c.c. of bloody serum
aspirated. Patient feels better but
physical signs persist. Diagnosis:
tuberculosis. Repeated aspirations.
Diilness increases in front and behind.
Left chest measures 2 cm more than
right. 900 c.c. greenish fluid aspirated.
Left jugular thrombosed; cedoema of
that side of face, neck, and shoulder.
2 more aspirations without result.
Thrombosis popliteal vein. Death
with intense dyspnoea and suffocation
about 2 1 months after admission

Cough, night sweats, dyspnoea, pain
in left chest, emaciation. Later pleu-
risy and signs of consolidation of left
lung; cyanosis; intense asphjrxia.
Duration about 6 months or over

Disease began with swelling of right
carotid, which gradually invaded right
side of neck and upper part right chest;
later left side also involved. Increas-
ing difficulty in breathing and swallow-
ing, dilated veins in chest and neck.
Cough, pain in chest, nocturnal attacks
of dyspnoea, cedoema of lower extrem-
ities. Dulness over right chest below
3rd interspace; diminished voice and
breathing ; from spine of scapula down-
wards bronchial respiration ; absence of
breathing at base. Left lung normal.
Duration about 9 months

SARCOMA

265

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMARKS

Mucoid, no

Tumor degeneration of

Bronchial,

Small round

Origin probably

tubercle

right main bronchus, some-

retrobron-_

celled sar-

from small lymph

bacilli,

what in left bronchus and

chial, cervi-

coma retain-

nodes within the lung

later

in trachea; at bifurcation

cal, axillary

ing alveolar

straw-

penetrates right upper lobe

lymph

structure of

berry col-

from hilus along bronchi.

nodes, skin,

lung due to

ored con-

Large bronchiectatic cavi-

liver, and

persistence of

taining

ties in lower lobe

kidneys

septa

bronchial

casts and

great

numbers

of large

round

epithelial

cells

At first mu-

Left lung almost entirely

Tumor

Round celled

coid,

replaced by large tumor

size of

sarcoma

later

everywhere adherent to cos-

orange in

bloody,

tal pleura. Tumor softened

liver with

finally

in some places and resem-

cavity in

typical

bles brain substance; in

centre con-

"currant-

other places grayish masses

taining col-

jelly," no

traversed by bands of fibrous

loid mate-

tubercle

tissue. No enlarged glands

rial. All

bacilli

at hDus. Veins in left neck
thrombosed and merged
into nodulated tumor at
base

other

organs

healthy

Repeated

In the lumen of bronchi.

No details

Spindle celled

hsemop-

on surf ace of lung and in

fibroplastic

tyses

lung tissue itself soft whitish
encephaloid masses

sarcoma

No details

Fluid in right pleura.

Bronchial

Round celled

Heart dislocated to left. All

lymph

sarcoma

of right lung except tip oc-

nodes

cupied by large nodulated

tumor. Enlargement of

right lobe of thyroid

266

TABLE II

POLLAK,

Dis. Wiirzbtirg, 1897

Ein Fall von primarem

Lungensarkom

M 71

POOHB,

The Lancet, London,

1895, I, p. 870

A Case of Tumor of the

Lung

Porter,

British Med. Jour.,
1885, II, 448

Powell,

Brit. Med. Jour. 1879,
p. 115

Sarcomatous Disease in-
vading the Lung and
Occluding its Bronchi

Ranglahbt,

Bull. Soc. Anat. de

Paris, 1893, Vol. VII,

p. 591
Sarcome primitif du

Poumon Gauche

Reymond, E.

Bull, de la Soc. Anat.

LUNG IN-
VOLVED

Not
stated

CLINICAL SYMPTOMS

Various tropical diseases. Death
with symptoms of icterus gravis

Quite healthy untU one morning on
getting up sudden shortness of breath.
Remained in bed for some weeks.
Later, while walking, severe pain in
back. Went to bed and then to
hospital. SHght dyspnoea on exer-
tion, slight cough. Left side impaired
respiratory motion. Below 3rd rib
absolute dulness. Absence of voice
and breathing over this area; some
bronchial breathing; similar condi-
tions below. Heart dislocated to
right. Aspiration negative. Left
chest increased in size; swelling in left
mammary region ; slight fever. Later
oedoema of left chest; dilated veins.
Small tumor over head of right
humerus. Dulness extended over to
right chest. No pain at any time.
Duration about 4 months

Dyspnoea, palpitation, cough. Pain,
dysphagia. CEdcema feet and left
forearm. Flatness upper left lung;
dulness at base; feeble voice and

breathing

Haemoptysis of 2 weeks duration.
Cough and haemoptysis recurred few
months later. Jaundice. Dulness at
base to spine of scapula and nipple
with diminished voice and breathing,
later extending over upper lobe. Pain
in chest; intense dyspnoea

No heredity. Pain in left chest.
Pregnancy; normal labor. Continued
pain; negative puncture. Later ex-
pansion of left chest. Flatness and ab-
sence of breathing sounds all over chest.
Harassing cough. Dislocation of heart
to right. Debility and emaciation.
Dilatation of superficial veins. Qildce-
ma of lower extremities. Bloody fluid
in left pleura. Diagnosis made during
life. Duration about 16 months

Sudden onset after "cold" with
dyspnoea, severe pains in left shoulder

SARCOMA

267

AUTOPSY NOTES

METASTASES

MICROSCOPE

No details

Scant, once
or twice
bloody

Bloody

Mostly
bloody

Mucoid and
bloody,
haemop-
tysis

Bloody, no
tubercle

From root of right lung
and extending along bron-
chial ramifications, medul-
lary infiltration, particu-
larly of the alveolar septa;
compression of bronchi and
blood vessels

Whole of left chest filled
with soft growth covered by
thickened pleura firmly ad-
herent to chest wall. Upper
anterior portion of tumor
covered by shell of collapsed
lung

Liver and
lymph
nodes of lig.
hepatoduo
denale

Large tumor occupying
entire left upper lobe, and
enveloping root, transverse
aorta, left carotid and sub-
clavian. Pneumonia in
lower lobe

Large lymphomatous
growth in posterior medias-
tinum occupying bifurcation
and extending into lung, in-
volving two lower bronchi
and completely occluding
the lower one. Middle lobe
entirely occupied by tumor.
Bronchiectases in lower lobe

Left lung totally replaced
by soft encephaloid tumor
with cavities containing
bloody and greenish con-
tents. Right lung normal

Nearly whole of left lung
converted into large tumor

Right lung,
mediastinal
lymph
nodes, liver
and over
humerus
and scapula

No details

Liver, left
kidney and
peritoneal
lymph
glands

Absolutely
none any-
where

Glands at
hilus only

Round celled
sarcoma pro
liferating
mainly in the
fibrous tissue
of the intra-
lobular and
intra-alveolar
septa of the
smaller
bronchi

Round celled
sarcoma

Lympho-sar-
coma

Spindle celled
sarcoma

Spindle celled
sarcoma; no

268

TABLE II

de Paris, 1893,
VIII, p. 256
Sarcome primitif
Poumon Gauche

Vol
du

72 ROLLESTON, H. D.

Transact. Path. Soc

of London, 1891, p. 54

Myxo-sarcoma of Lung

RoLLESTON & Trevor,
British Med. Jour.,
Feb. 14, 1903

Primary Sarcoma of the
Lung

Roth, Ludwig,
.. Diss. Miinchen, 1904
Uber primares Lun-
gensarkom, etc.

Rttetimeyer,

Corresp.-blatt fiir
Schweizer Arzte,
1886, XVI, 169-199

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

radiating into arm and fingers. Im-
proved for a time, but symptoms re-ap-
peared with loss of flesh and haemopty-
sis. Examination then showed nothing
but slight pericardial friction. Clinical
diagnosis at that time: rheumatism
with dry pericarditis. Later increas-
ing pain, slight fever. Bulging of left
chest; heart dislocated to right. Flat-
ness from left clavicle downwards;
diminution of breathing sounds. Re-
peated cultures negative. Heart
sounds heard clearly all over left
chest. Blood normal. Fever up to
104. Duration about 5 months

No clinical history except that
paracentesis of thorax gave mucous
fluid

Recurrent pains in right chest and
all symptoms of empyema. Aspira-
tion at first negative; later small
amount of bloody fluid. Resection
of rib showed solid growth

Always well. December, 1902, pain
in chest and cough. Got better, but
had renewed attack in Jan., 1903.
Never quite well since then. In
beginning of May, 1903, severe pain
in chest and back; impossible to walk
upright. While walking sudden feel-
ing as if something burst in his ab-
domen. Signs of paralysis after that.
On admission 10th to 12th thoracic
vertebrse very tender; to the left
of their spines a fluctuating tumor
presents size of the palm of the hand.
Flatness over entire right apex.
Rales over both lungs. Clinical
diagnosis: tuberculosis of lungs and
spine. Later puncture of abscess.
Rapid decline, intense dyspnoea. Pains
in both legs; emaciation; death

No heredity. Sudden onset with
pain in side and moderate fever. Pain
disappears; some dyspncsa remains;
dry cough. Chills and fever; dulness
over left base. Exploratory puncture

SARCOMA

269

SPUTUM

AUTOPSY NOTES METASTASES

MICROSCOPE

EEMARK8

bacilli

filling greater part of chest.
Some remnants of lung tis-
sue under pleura. Cavity in
centre of tumor contains
large amount of fresh blood

remnants of

pulmonary

structure

No details

Left lower lobe completely

Bronchial

Small celled

occupied by a mass of new

glands; 8th,

myxosarcoma

growth almost completely

9th and 10th

replacing lung tissue. Upper

left ribs

lobe compressed and infil-

trated with new growth in

its lower parts. Parts of

the tumor calcified; honey-

combed in parts with cysts

containing gum-like fluid

consisting chemically of al-

bumin and mucin. The

tumor projects into pericar-

dial- cavity

No details

Whole right lung except
apex converted into soft
gruel-like growth with hsem-
orrhagic areas

None

Spindle celled
sarcoma

Bloody sev-

Right lung adherent. Ne-

Peribron-

Alveolar

Author designates

eral

oplasm size of a fist in right

chial glands

structure ;

the tumor as a small

weeks

upper lobe. Pneumonic in-

stroma of fi-

round celled sarcoma

before

filtration of lower lobe.

brous_ strands

probably originating

death

Bronchi infiltrated with
tumor. Tumor almost com-
pletely replaces lung tissue

containing
dilated and
congested
blood vessels.
Tumor con-
sists of small
round cells
with large
nuclei and
small proto-
plasmatic
bodies. Walls
of alveoles
lined with
similar cells.
Large areas
of tumor ne-
crotic

in lung itself

Green, later

Whole left lower lobe

None any-

Small round

Origin from lung

severe

practically one large tumor

where

and spindle

tissue itself

haemop-

surrounded by thin layer of

celled sar-

tysis

compressed lung tissue.
Bronchi normal

coma

270

TABLE II

NO.

AUTHOR

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

negative. Later flatness with absence

of voice and breathing over left base.

CUnical diagnosis: encapsulated em-

pyema. Rib resection showed soft,

reddish tumor masses in lung. Dura-

tion about 2 years

Sangalli,

Gaz. med. Lombarde,
1897, p. 226

Osservazione sul Sar-
coma della Pleure e
dei Polmoni

Both

Increasing dyspnoea

Loc. CIT.

Clinical diagnosis: right pleurisy
with effusion. Aspiration negative.
Increasing cough, dyspnoea, dysphagia.
Bougie in oesophagus showed nothing

SCHECH,

Virch. Arch. f. klin.
Med., Vol. 47, 1891,
p. 411
Das primare Lungen-
sarkom

Acute onset with profuse haemop-
tysis. Nothing found on lungs.
Repeated severe hsemoptyses. Year
and half later slight dulness, dimin-
ished fremitus and absence of breath-
ing over right base. Some rales.
Embolism was suspected. No dysp-
noea, fever, pain, or emaciation.
Repeated hgemorrhages. Year later
dyspnoea, intense pain, cough. Grad-
ually complete paralysis up to mam-
miUary line. Increase of dulness over
entire right chest. Duration of dis-
ease at least 3 years

SCHNICK,

Diss. Greifswald, 1899
Ein Fall von primarem
Spindelzellensarkom
der Lungen gepaart
mit Tuberkulose

3 weeks before admission bloody
sputum and pain in right chest. In-
creasing dyspnoea and weakness. Phys-
ical signs of tuberculosis in both
apices. Hectic fever. Dulness over
upper portion right chest; loud vesic-
ular breathing; rales

Shewen,

Austral, med. Gaz.,
1885, Vol. IV, p. 81

Case of Sarcoma of Left
Lung involving the
Diaphragm and the
Spleen

Chill and congestion of lung; never
quite well after. Gradually dyspnoea,
enlargement of left chest. Dilated
veins; heart displaced to right. Dul-
ness with absence of voice and breath-
ing over left chest. No cough, _ no
fever, no pain. Aspiration negative.
Tumor diagnosed during life. Dura-
tion of disease between 2 and 3 years

SiLVA,

Gaz. degli Ospidali e

No heredity; no lues. Illness be-
gan 7 months ago with difficulty in

SARCOMA

271

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

EEMAHKS

No details

Numerous nodules in both
lungs, more in right, often
confluent and merging into
large masses

No details

Round celled
sarcoma with
calcification

No details

Old tuberculosis of left

Bronchial

Round celled

apex; numerous larger and

and medias-

fibro-sarcoma

smaller nodules throughout

tinal lymph

right lung, also strips of in-

nodes and

filtration of white tumor

oesophagus

throughout lung. Tumor

proliferates into wall of

oesophagus. Tumor masses

surround and compress de-

scending aorta, oesophagus,

both bronchi, and right

auricle

Purulent,

Bloody fluid in right

Spleen;

Round celled

green

pleura. Almost entire right
lung converted into firm
white tumor mass enclosing
cavities filled with necrotic
material. Left lung normal

pleura.
Brain and
cord not
examined

fibro-sarcoma

Profuse,

Fresh endocarditis. Tu-

None

Typical

muco-

berculosis of both lungs. In

spindle celled

purulent,

right middle lobe a large

sarcoma

occasion-

tumor, encapsulated and

ally

containing a cavity filled

bloody ;

with degenerated tumor ma-

contains

terial ; in part chalky degen-

tubercle

eration; numerous tubercle

bacilli

bacflli

No details

Left chest entirely occu-

Diaphragm

Small round

Origin from bron-

pied by tumor of left lung

and spleen

celled sar-

chial glands

displacing heart and com-

coma

pressing right lung

Tenacious,

Bloody fluid in left pleura.

No details

bloody,

Nearly whole of left lung

272

TABLE II

della cliniche Milana,
XXIII, 1902, seria 11,
p. 1236

Sul Sarcoma primario
del Pulmone

Smith, W. G.
Dublin Jour.
Science, 1881,
72, p. 452

Med.
Vol,

SPILLMAJm AND HaUS-
HALTER,

Gaz. Hebd., 1891, p.

587

Du Diagnostic des Tu-

meurs malignes du
Poumon

Steell, Geaham,
Lancet, 1894,
I. p. 388,
Clinical Lecture
on Case of Tumor
of Lung

'LUNG IN-
I VOLVED

Not
stated

Sutton,

Lancet, 1869, I, p.
459

CLINICAL SYMPTOMS

swallowing. For 1 month icterus and
mUk diet. For 5 months severe
cough; no fever. Some nausea, but
rarely vomiting. Severe pain in
epigastrium and behind sternum radi-
ating to left chest and shoulder. On
admission much emaciation. Im-
paired respiratory motion of left chest;
flatness over whole left chest except
shght space at base. All over flat
area absence of breathing and frem-
itus. Oesophageal sound finds resist-
ance 32 cm. from teeth. Puncture
jaelds only a few drops of blood;
needle enters hard, firm tumor mass.
Gradual decline; intensest dyspncsa,
cyanosis. Slight fever. Clinical diag-
nosis: primary sarcoma of lung

Pleurisy of right side 2 1 years before.
Since then never quite himself ; breath-
ing always short. Later principally
cerebral sjonptoms, paralysis,_ etc.,
due to haemorrhage and softening in
pons. 4 or 5 weeks before death
haemoptysis, cough. Dulness below
_ht clavicle extending downwards;
complete absence of breathing sounds.
Later temperature to 102. Later
complete dulness of entire right chest.
Excessive sweating; foetid breath.
Duration of illness from development
of paralysis, 3 months

Occasional pain in left chest; biil-
gmg of entire left chest. Irregular
areas of dulness increasing to flatness;
absence of voice and breathing.
Emaciation and sweating. Various
symptoms referable to the heart. No
dyspnoea; no cough. Duration of
disease about 2 years

Good health until haemoptysis,
followed by failure of health. No
cough, no expectoration, and no
physical signs on lungs for months.
Later much pain in right chest and
large quantities of putrid expectora-
tion as from ca\dties. Upper right
chest fuller than left; impaired res-
piratory motion. Absolute flatness
o f upper right lobe with later de-
velopment of tympanitic sounds and
other signs of cavity. Dilatation of
veins of upper right arm and right
chest. Slight temperature shortly be-
fore death

Cyanosis, dyspncea. Absolute flat-
ness and absence of breathing sounds
throughout left chest. Heart dis-

SARCOMA

273

no tuber-
cle bacilli

transformed into hard, dark,
greenish tumor mass

Repeated
haemop-
tysis

None

AUTOPSY NOTES

Right lung adherent. En
capsulated empyema with
putrid pus. Upper | of lung
converted into lobulated
tumor separated by highly
pigmented septa. Lower
third completely gangrenous

None at
first, later
abun-
dant, ex-
tremely
foetid. No
micro-
scopic ex-
amina-
tion

No details

Large tumor filling nearly
all of left chest dislocating
heart to right and pushing
diaphragm downward. Ori
gin of tumor right upper
lobe. Peripheral areas of
tumor surround a cyst-like
central mass; entire central
mass surrounded by com
pressed lung tissue

Both pleurae adherent.
Right pleura practically ob-
literated; no effusion. Large
cavity in right upper lobe
with irregular soft walls of
grayish-white tumor. Tu
mor size of a small orange
projects into cavity. Only
slight traces of lung tissue
remain in upper lobe

Medullary cancer occupy-
ing entire left chest. " Left
lung collapsed, pushed back-

METASTASES

Mediastinal

lymph

nodes

None

None; not
even in mid-
dle and low-
er right lobe

MICROSCOPE

Small round
celled sar-
coma

Cystic
fibro-sarcoma

Simply said
to be lympho-
sarcoma

None

No details

274

TABLE II

A Case of Medullary
Cancer of Lung simu
lating Pleuritic Effu-
sion

Vandervelde, Paul,
Jour, de Med. Chir.
et Pharm. Bruxelles,
Vol. 94, 1892, p. 193

Un Cas de Sarcome en-
cephaloide primitif du
Poumon, etc.

Walch,

Bull, de la Soc. Anat.
1893, p. 90

Cancer du Poumon
gauche; generaliza-
tion; Pleuresie puru-
lente h pneumoco-
ques

Weiss,

Miinch. med. "Woch.,
1895, p. 790

Zwei gleichzeitig beo
bachtete Falle von
bosartiger Neubil-
dung in den Lungen
resp. Mediastinum
anticum

White, W. Hale,
Transact. London

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

located to right. Right chest smaller
in circumference than left. First
puncture, a little dark blood; second
"something hke pus."

Tubercular family history. About
2 years before admission pleuro-
pneumonia; in bed 5 weeks; never
entirely well since then. Attacks of
profound dyspnoea at short intervals;
pain in right chest. 6 months before
admission a tumor was noticed in right
chest, growing rapidly and causing
much pain. On admission loss of
appetite; no cough; no expectora-
tion. Pain in chest; much oppres-
sion. Soft fluctuating tumor of 6th
to 8th ribs covered by healthy skin.
Probatory puncture recovers a few
drops of thick, grayish-yellow fluid
containing numerous sarcoma cells.
Most of the lung had undergone
mucoid degeneration; no tubercle
bacilli. Tumor was removed by
operation and pedicle was found pro-
jecting into pleural cavity. Both
leaves of the pleura were adherent
to tumor, allowing it to be removed
without opening the pleural cav-
ity. Uneventful recovery. Patient
re-enters hospital about 6 months
later with emaciation, anorexia,
night sweats, intense dyspnoea, haras-
sing cough. Almost no respiratory
movement of right chest; flatness;
rales

Disease commenced with pleurisy;
never well since then. Intense dysp-
noea; pain in left chest. Spells of
coughing, loss of flesh; dulness over
left chest; loss of breathing and frem-
itus. Other organs normal. Tem-
perature up to] 104. Profuse night
sweats. Aspiration yields pus. Oper-
ation:_ very slight quantity pus, which
contains pneumococci in pure cul-
ture. Fever remains after operation.
Entire clinical picture dominated by
empyema

Always healthy. Much cough; mu-
cous rales over both lungs, but no
dulness. Rapid loss of weight and
strength. Continuous high fever.
Small tumor above left clavicle, others
in left axilla, right inguinal fold and
below clavicle. Spleen much enlarged
and hard. Death in coma. Clinical
diagnosis: acute miliary tuberculosis.
Duration not quite 2 months

Loss of appetite, flesh, and strength.
Pain, dyspnoea, dysphagia. Aspira-

SARCOMA

275

AUTOPSY NOTES

METASTASES

MICROSCOPE

Purulent,
often
bloody,
no tuber-
cle bacilli

wards and spread out over
cancerous mass "

Scar infiltrated with tu-
mor and adherent to right
lung. Whole right lung re-
placed almost entirely by
soft yellowish tumor. Lung
tissue compressed and stud-
ded with tumor nodules. In
centre a cavity containing
blood and detritus

Bronchial
glands and
resected ribs

Operated
tumor shows:
alveolar
structure ;
small round
celled sar-
coma with
mucoid de-
generation;
no epithelial
or giant cells

After careful search
and study of all other
organs, tumor was
pronounced primary
in lung

No details

Entire left lung trans-
formed into firm tumor ad-
herent to chest wall

Bronchial
IjTnph
nodes, peri-
cardium,
right lung,
liver

Medullary
sarcoma

Repeated
haemop-
tyses, no
tubercle
bacilli

Both lungs studded with
sarcoma nodules, especially
left upper lobe, surrounding
bronchi and proliferating
into their lumen

Various
lymph
nodes, liver

Several hse-
moptyses

Left bronchus completely
surrounded and obstructed

Left recur-
rent laryn-

Round celled
sarcoma

Doubtful if primary
in lung

276

TABLE II

NO.

AUTHOR

SEX

AGE

LTJNQ IN-
VOLVED

CLINICAL SYMPTOMS

Path. See, Vol. 44,

tion: bloody fluid from left pleura.

1893, p. 14

Dilated veins over left chest. Heart

dulness extended to right. Difference

in pupils. Duration of disease about

9 months

WiLKS,

Trans. London Path.
Soc, Vol. IX, 1857,
p. 31
Fibrocelliilar Growth of
the Lung

Dyspnoea, dulness over left chest.
Dropsy

SARCOMA

277

No details

AUTOPSY NOTES

by tumor; infiltration of left
upper lobe; portion of lung
gangrenous. Tximor com-
municates with small growth
behind left sternocleido
muscle. Compression of pul-
monary artery, veins, and
aorta by tumor. Aorta and
oesophagus ulcerated and
perforated by gangrene

Tumor occupied nearly
whole of left chest, destroy-
ing lower part, compressing
upper of lung. Root not
affected but adherent to
chest wall

METASTASES

geal nerve

Posterior
mediastinal
glands

MICEOSCOPE

Fibro-sar-
coma, long
nucleated
fibres with
nucleated
ceUs inter-
spersed, in
some parts
very rich ii
round cells

Author remarks
that in appearance
and behavior it re-
sembles more the
non-malignant than
the malignant type

278

TABLE III

Adam, G. R.

Glasgow Med. Jour.
1879, pp. 31-37

Log. cit.

Adams,

London Path. Soc,
1848-50, II, pp. 174-
177

Ad AMI,

Montreal Med. Jour.,
Vol. XXIV, 1895, p.
510

A Case of Malignant
Intrabronchial
Growth Associated
with a Misleading
Train of Symptoms

AVIOLAT,

Th^se de Paris, 1861
Du Cancer du Poumon.

Bennett, J. Risdon,
Intrathoracic Growths
London, 1872

Bernard et Vermorel
Bull, de la Soc. Anat.
de Paris, 1894, pp.
251-253

Cancer du Poumon avec
^panchement pleural
sero-sanguinolent

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

Pain in chest and dyspnoea for 15
months. Dulness from right apex to
nipple; absence of breathing sounds

Cough, dyspoena, pain in left chest;
deficient respiration; no vocal frem-
itus. Dulness from clavicle to 5th rib.
Left chest half inch more in circumfer-
ence than right. Later aphonia and
dysphagia

No symptoms until 2 weeks before
admission, then dyspncBa and slight
cough; later cyanosis. Small tumor
below right clavicle

Died 4 hours after admission. One
year before beheved to have incipient
tuberculosis of right apex. Whole
right side dull; cavernous breathing
above; feeble breathing below.
Clubbed fingers; cyanosis

No heredity. Some pain, dyspnoea,
increasing weakness. Brain symp-
toms (strabismus, headache, formica-
tion of arms, vomiting) at an early
stage. Right lung normal. Dulness
over left anterior chest with bronchial
respiration. Later flatness with ab-
sence of voice and breathing

Cough, pain in left side; increasing
emaciation and debility. Consider-
able scoliosis

No ascertainable heredity. For 6
years cough each winter with abund-
ant expectoration. Dates sickness 4
months before admission, when increas-
ing weakness and dyspnoea on slight
exertion. On admission no marked
loss of flesh; night sweats. No lesions
anywhere except on lungs. Left lung

DOUBTFUL

279

No expecto-
ration, ^
ounce of
blood at
late stage

White,
never
bloody

Scant

Yellowish,
mucopu-
rulent

Not men-
tioned

None; no
haemop-
tysis

Scant, mu-
copuru-
lent; at
times
pink. No
tubercle
bacilli

AUTOPSY NOTES

Cancer nodules through-
out entire right lung

Upper part of left lung
occupied by nodular mass
extending up to thyroid,
enclosing aorta and roots of
cervical vessels. Heart dis-
placed to middle line

Both lungs studded with
spherical, well demarcated
tumors of all sizes. Upper
cava compressed. No effu

Lobular consolidation at
left base; purulent bronchi-
tis. Right lung adherent;
interstitial pneumonia of up
per lobes and bronchiectasis.
No signs of tuberculosis
Right lower lobe completely
collapsed and adherent to
diaphragm. Saccular dila-
tation of left main bronchus
which is obstructed by large
soft tumor proliferating up
ward into the bronchus and
obstructing it

Several cystic tumors in
the brain. Clear serum in
left pleura. Upper left lobe
and its bronchi a mass of
nodulated tumor

Both pleurae adherent.
Right lung large; left small
and misshapen on account
of scoliosis. Both lungs
studded with grayish white
tumors. Both lungs dis-
tinct and diffuse cancerous
infiltration. Lung tissue
between infiltrated portions
normal

METASTASES

Glands of
thorax

Sanguinolent effusion in
right pleura. Lung com-
pressed upward. Large tu-
mor in upper mediastinum,
white and hard, extending
slightly to left, but main
bulk in right chest; tumor
has replaced greater part of

Lymph
nodes of
neck and
mediasti-
num ; both
kidneys and
right supra-
renal

Bronchial
and cervical
lymph
nodes and
liver

Peribron-
chial lymph
nodes

MICROSCOPE

Not given

Author calls
it "Fungus
haematodes"

Alveolar
structure
that resem-
bles carci-
noma; many
cells like sar-
coma

None

Liver

Bronchial
lymph
nodes. No
other metas-
tases any-
where

Not given

No details

Adami is inclined
to call it sarcoma

Possibly sarcoma

Author simply
states that the tumor

Not recorded Probably carci-
noma

280

TABLE III

NO.

AUTHOR

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

healthy except some moist rales. Right

chest immobile on respiration and all

signs of pleural effusion. Aspiration,

1800 c.c. yellow serum. Dyspnoea im-

proved but dulness remained all over

upper right lung. Tumor of lung ia

suspected in spite of good appetite.

lack of cachexia and non-characteristic

sputum. Sudden attack of intense

dyspnoea; probatory puncture in

upper lobe seems to enter solid tumor.

OEdoema of lungs. Death

BiBBBATTM,

Preusa. Vereinszeit.,
N. F., V, 31, 1862
(after Reinhard)

Pain in left hypochondrium ; harass-
ing dyspnoea; no cough. Left chest
dilated; some dulness; normal auscul-
tation, ffidoema of feet and hands

BOUILLAXTD,

Jour. comp. du Die.
des Sciences Med.,
1826, Vol. 25, p. 289
Observations sur le
Cancer des Poumons

Over 3 months in hospital but chest
not examined as patient was in sur-
gical ward. Dry cough, rapid maras-
mus, hectic fever. Swelling, supposed
to be cancerous, of right lachrymal
gland

Bricheteau,
Gaz. des Hopit. de
Paris, 1833, VII, p. 281

D6gen6rescence squir-
rheuse de la presque
totality d'un Poumon
etc.

When admitted to hospital was so
weak he could not be examined. Ex-
treme emaciation; high fever; en-
larged left axillary glands. Hard
tumor over left clavicle. Dulness
over left chest. Clinical diagnosis:
acute phthisis

BUDD,

London Medico-Chir.
Trans., 1859, Vol.
XLII, p. 215
On Some of the Effects
of Primary Cancerous
Tumors within the
Chest

Good health until attack of pneu-
monia in right lower lobe; since then
short breathing; later pain in lower,
right chest. Gradual loss of strength,
cough, dulness and inaudible respira-
tory murmur over lower right chest.
Later cedcema of right chest and face;
enlargement of superficial veins; fric-
tion over precordial region; intense
dyspnoea; purpuric spots. Enormous
enlargement of veins over right chest
and belly. Duration of disease about
2 years

Loc. CIT.

Always well. After a cold, pain in
right chest posteriorly, later anteriorly.
After a week well, then cedcematous.
Dilatation of veins of chest and epi-
gastrium. Dyspnoea, hoarseness,
cough ; later vomiting. Fever, intense
dyspnoea; death. Duration about 6
months

DOUBTFUL

281

Frothy mu
cus tinged
with
blood.
Later
greenish
pus

AUTOPSY NOTES

right upper lobe and envel-
ops origin of anterior me-
diastinum, trachea, arch of
aorta, and both pneumogas-
trics, proliferating slightly
into trachea at bifurcation.
Left lung healthy

Entire left lung converted
into medullary tumor except
small portion at apex.
Pleura adherent. Right
lung displaced

Upper left lobe almost
completely converted into
whitish tumor. No ulcera-
tion; no cavity. "Cancer-
ous polypi" in posterior
nares

Right lung normal. En-
tire left lung transformed
into a hard, bluish, marbled
tumor showing no remnants
of pulmonary structure; no
softening, no suppuration,
no ulceration. Tumor ad-
herent to pleura in upper
portion. Yellow serum in
pleura. All other organs
normal

Lower part of right chest
occupied by a white can-
cerous mass; extending to
mediastinum; tip on level
with clavicle. Penetrates
upper cava, projects into
right auricle enclosing root
of lung. Large bronchi pen-
etrated by tumor and nar-
rowed but not closed.
Large bronchiectatic cavity
filled with pus in upper lobe
Pericarditis

Firm, nodular, yellowish
white tumor in mediastinum,
penetrating into right lung.
Upper cava, right innom-
inate vein and part of left
involved in tumor, which
also projects into pericar-
dium. Tumor penetrates
trachea ^ inch above bifur-
cation and down right main
bronchus. Small nodule in
left bronchus

METASTASES

Right lung
and liver

No others

None

No others
mentioned

Bronchial
and tracheal
glands

MICROSCOPE

Not men-
tioned

Not given

No details

None given

Probably sarcoma

Doubtful whether
bronchial carcinoma
or sarcoma

Probably primary
in mediastinum and
sarcoma

282

TABLE III

Bttdd,
Loc. cit.

BUREAIT,

Bull, de la Soc. Anat.
de Paris, V, Serie 10,
1896, p. 26
Tumeur de hile du Pou-
mon droit. Pleuresie
droit

BlTRROWS,

Med. Chirurg. Trans.,

1844

Cannstatt,

Hannover. Annalen
fiir die gesammte
Heilkunde, Vol. V,
.. 1840, p. 433
Ahren-lese au3 der
Praxis

Chahteris, M.

Lancet, 1874, I, p.

126
On Intrathoracic Cancer

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

Always well. Illness commenced with
cough, shortness of breath. 3 weeks
before admission swelling of face; no
pain. Dulness and diminished voice
and breathing over greater part right
chest in front. Heart sounds are heard
loud over the dull area of right chest.
Dilated veins over chest on both sides.
Increasing oedcema of chest, face, and
arms. Intense dyspnoea. Death from
asphyxia. Duration about 7 months

For some years always aware of
some trouble in chest. Frequent
attacks of bronchitis and strong op-
pression on climbing or walking
briskly. No palpitation, but violent
pains behind sternum. Diagnosis of
angina pectoris was made, for which
she was treated in hospital. Improved
and for some years the attacks of pain
and oppression disappeared entirely.
A few days before admission to the
hospital while on train to Paris, sudden
chill and violent pain in right chest.
On admission flatness at the right base,
loss of fremitus, faint distant breath-
ing. All other organs normal. No
cyanosis, no oedcema ; no cardiac symp-
toms. Later slight rise of temperature.
Aspiration dark yellow serum. Rapid
refilling of chest. Three punctures with
increasing amount of serum. Notwith-
standing punctures dyspnoea increases
to most intense orthopnoea. Suddenly
hsemopytsis and death. Duration of
the acute stage only a few months

First symptoms 6 months before ad-
mission, then pain under sternum, cough
and loss of appetite. Better for a time,
then dyspnoea, emaciation, and sweat-
ing. Dulness on upper right chest, in-
creasing to flatness. Feeble bronchial
respiration. CEdcema of face, right
hand, and arm. Duration of disease
a little more than 6 months

Profuse hsemoptyses. No pain.
Dulness over left chest; pectoriloquy

For 3 months hoarseness, vomiting of
food and blood ; loss of weight, increas-
ing weakness. On admission cough,
dyspnoea, dysphagia, persistent vomit-
ing. Rales all over chest. Posteriorly
dulness at angle of right scapula. Par-
alysis of left vocal cord. Death after
increasing dyspnoea and weakness

DOUBTFUL

283

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

BEMABKS

Bloody;
profuse
hajmor-
rhage

Serous fluid in right pleura.
Whole of right upper lobe
converted into solid white
tumor included in enormous-
ly thickened pleura. Below
right main bronchus a scir-
rhous mass, size of a small
apple invading but not con-
stricting bronchus, com-
pressing upper cava. Few
nodules in left upper lobe

Left lung
bronchial
glands

None

Origin probably in
bronchial glands.
Possibly sarcoma, but
probably bronchial
carcinoma

Haemopty-
sis

Abundant fluid in right
chest. White, very hard
tumor at root of right lung
adherent to pericardium.
The lung is of the size of 2
fists, and the tumor starting
from the hilus penetrates
deeply into the lung tissue.
Right main bronchus com-
pletely obstructed

Tracheal
and bron-
chial lymph
nodes

None given

Difficult to say
whether we have to
deal here with sar-
coma or carcinoma.
It is probably carci-
noma

Haemopty-
sis and
currant
jell5' ex-
pectora-
tion

Right chest larger than
left. 2000 c.c. brown fluid
in right pleura._ White, lob-
ulated tumor in lower and
middle lobes. Bronchiec-
tatic abscesses. Compression
of right pulmonary veins,
right carotid, and internal
carotid

Cervical,
axillary, and
mediastinal
lymph
nodes

None given

Author calls the
growth cancer. It is
probably sarcoma

Profuse,
foul, pu-
trid.
Profuse
haemop-
tysea

In left lung cavity larger
than man's fist, the walls
of which are thickened and
made up of scirrhous mate-
rial

Bronchial
glands

Not men-
tioned

Foamy,
abundant

Tumor at bifurcation
branching into bronchi of
both lungs, especially right.
Involvement and compres-
sion of oesophagus. Left re-
current laryngeal also in-
volved

Not men-
tioned

Numerous
round cells
surrounded
by vascular
connective
tissue

Probably Barcoma.
LA.

284

TABLE III

Clark, A.
Lancet, 1856

Cockle,
Association Med.
Jour., London, 1854,
p. 990

De Boter, H.

Le Progres. Med., Ill,

1875, p. 87
Adenopathie bron-

chique Cancereuse

De Renzi,

La Riforma Med

Napoli, XIV, 1898,

Vol. I, p. 747
Un Caso di Carcinome

del Polmone

De Valcourt,
Revue Med., Ill,
XVIII, 1874, 723
Press. Med. Beige,
Bruxelles, 1874, Ann.
26, p. 406

Cancer pulmonaire,
compression, etc.

LTJNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

Clinical signs of pulmonary phthisis.
Night sweats; diarrhoea

Laryngeal cough, hoarseness, dysp-
noea, dysphagia, fever. Follicular
affection of throat. No signs on lungs

Testicle removed for suppuration
two years before admission; thereafter
legs became swollen and painful; dysp-
noea on walking; chronic bronchitis.
Loss of weight and strength, hoarseness,
night sweats. Examination on admis-
sion revealed a hard gland, size of a hazel
nut, in left supraclavicular region. Dul-
ness over sternum and posteriorly be-
tween scapulae. On right side anteriorly,
distinct murmur-like sounds simulating
aneurysm, also faint rales. Over area
corresponding to tracheal bifurcation
bronchial breathing. Cough character-
ized by whoop. Dysphagia, aphonia,
slight albuminuria. Death during an at-
tack of dyspnoea 13 days after admis-
sion, glands having rapidly increased in
size. Diagnosis: tuberculosis of bron-
chial glands

For 2 years cough; 8 months pain in
left shoiilder (patient was accustomed
to carrying heavy loads on left shoulder
and continued to do it notwithstanding
the pain). For 3 months hoarseness,
loss of strength and weight, harassing
cough. On admission left supra- and
infra-clavicular fossse are abolished and
bulging so that left clavicle is hardly
visible. Bulging occupies nearly all of
left shoulder and supraspinous region,
extending down to interscapular space
to left of vertebral column. Over all
the swollen region dilated superficial
veins, impaired respiratory motion.
Dulness and diminished respiration
and fremitus over all this region. Left
supraclavicular, axillary, and inguinal
glands enlarged. No fever. Paralysis
of left recurrent laryngeal. Intense
pain from left shoulder through arm.
Blood examination showed very
moderate secondary anaemia; no leu-
cocytosis. All other organs healthy

Dyspnoea, cachexia, complete apho-
nia, cyanosis, dysphagia. Left thorax
depressed, right increased in volume;
dulness throughout; diminished breath-
ing. Tracheotomy to relieve dyspnoea

DOUBTFUL

285

Haemopty-
sis

Purulent,
blood-
stained

Foamy,
mucous,
streaked
with
blood

AUTOPSY NOTES

Scant, mu-
copuru-
lent, con-
tains no
tubercle
bacilli

Mucoid

Tumor in upper part right
lung extending into lung
from periphery. Bronchi
filled with cancer cells

Both lungs studded with
nodules. Softening and cav'
ity in upper left lobe. Su-
perficial ulcer in larynx

Both lungs medullary
nodules; at base of both
lungs small subpleural nod-
ules. Bronchial glands en-
larged and fill entire medi-
astinum, compressing aorta,
thoracic duct, vena cava

METASTASES

No details given. Stated
'Diagnosis confirmed"

Enormous right lung that
had dislocated heart to-
ward left. Right lung lar-
daceous, semi-transparent,
and hard. Compression
right bronchus

Not men-
tioned

Mediasti-
nal lymph
nodes

Liver, ret
roperitoneal
glands; bal
ance men-
tioned under
autopsy

MICBOSCOPE

No details

Liver, tra-
cheal and
bronchial
lymph
nodes

Not men-
tioned

No details

Not given

Possibly sarcoma

(?)

Tumor is called en-
cephaloid cancer

No details

Not given

Possibly sarcoma

286

TABLE III

NO.

ATJTHOB

S£X

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

DOMBROWSKI,

Jahresbericht der
Schles. Gesellsch. fiir
Vaterl. Cult., 1901.
Breslau, 1902, p. 115
Ein Fall von Tximor der
linken Lunge

Always weU until one month before
admission, then pain in left chest,
cough, dyspncsa. Impaired respiration
left upper chest; bulging left supra-
clavicular region. Left breast larger
than right; small hard glands in both
axillae. Dulness descends from above
left clavicle, merges into heart
dulness, extends into axilla and
posteriorly to 4th thoracic vertebra.
Absence of breathing over dull area;
later faint vesicular breathing. X-ray
showed deep shadow over left upper
lobe. Clinical diagnosis: tumor of
left lung

Elliot,

British Med. Jour.,
April, 1874

Pain in right chest; complete flat-
ness; absence of breathing, dyspnoea,
harassing cough. Duration 7 months

Fagqe,

Trans. London Path.

Soc, 1867, XVIII,

pp. 29-31
Disseminated Primary

Cancer of Lungs

Both

Orthopnoea, cough, debiHty. Dul-
ness, slight bronchophony and sibilant
rgiles at base of each lung posteriorly,
especially left. CEdoema of legs. Sud-
den death

FUCHS,

Diss. Miinchen,
Beitrage zur Kennt-
niss der primaren
Geschwtilstbildungen
in der Lunge

No clinical history

LOC. GIT.

Diagnosed during life as pleurisy
and later as empyema

Gat,

Boston Med. & Surg.
Jour. Vol. 94, p. 6
Encephaloid Cancer of
Lungs

Difficulty in respiration, cough, in-
creasing dyspnoea. Loss of strength.
Pain in region of liver. Cough sub-
sides; dyspnoea increases. Dulness
over left base increasing to flatness
all over left chest except at apex.
Aspiration, at first clear yellow fluid;
later bloody. Duration of disease
about one year

Gordon,

Dublin Hospital Gaz.

1854-5, I, 94
Malignant Tumor in

Apex of Right Lung

Cough, pain in right chest, cyanosis,
dyspnoea. Dulness and feeble breath-
ing over right apex. Later swollen
glands above clavicle. Paralysis and
oedcema of right hand. Right side of
face swollen. Purpuric spots fol-
lowed by gangrene in cEdoematoua
portion. Duration about 4 years

DOUBTFUL

287

AUTOPSY NOTE3

METASTASES

MICROSCOPE

Bloody,
raspberry
jelly; no
tubercle
bacilli

None

No details

Not given

Fluid in right pleura. Al-
most entire right lung con-
verted into "cancer"

Small node
in right au-
ricle and
aorta

Clear brown fluid in both Pericar
pleurae. Both lungs studded jdium, right
with cancerous deposits re- auricle, left

sembUng tubercles

Clear serum in left pleura.
In left upper lobe a softened,
difl'usely infiltrated area
filled with greenish matter

Fibrinous exudate in right
pleura. Greater part of up-
per right lobe converted into
a soft lardaceous tumor

Both lungs
and pleura
bronchial
lymph
nodes, and
liver

Sanguinolent fluid in left Bronchial
chest. Lung compressed up- lymph
ward and backward. Entire nodes, both
pleural surface infiltrated lungs, kid-
with encephaloid cancer, neys
Left lung filled vsdth nod-
ules; nodules also in right
lung. Cancerous infiltra-
tion of pleural lymphatics

_ Small primary tumor in Subclavian
right apex. Obliteration of Ij^mphatic
subclavian vein; compres- nodes, liver
sion of axillary artery and
brachial plexus

ventricle,
Hver

None

No details

Author says
soft area is a
cancerous in-
filtration,
consisting of
spindle cells
and large
round epithe-
lioid cells

Not given

No data
given. Sim-
ply called en-
cephaloid can
cer

No data given

Doubtful whether
carcinoma or sarcoma

Probably sarcoma

Possibly sarcoma

Primary seat of
neoplasm probably in
pleura

288

TABLE III

^u.

AUTHOR

SEX

AGE

VOLVED

CLINICAL SYMPTOMS

Graves,

London New Syden-
ham Soc, 2d Edition,
Vol. 2, p. 70

Clinical Lectures on the
Practice of Medicine

Pain in right chest, cough, dyspncea,
hoarseness. Later oedoema of face and
neck; dilated veins. Dulness and
tracheal respiration. Impaired mo-
bility over all of right chest; no rales.
Left chest normal. Heart sounds
heard very distinctly over posterior
aspect of right chest. Enlarged liver,
jaundice; dysphagia, increasing dysp-
noea and CEdcema. Secondary tumors
on lower jaw, forehead, and near lum-
bar spine

Green,

Lancet, 1898, II, p.
1705

Debility, dyspnoea, signs of consoli-
dation of left lung and effusion into
pleura. Enlarged glands above right
clavicle

Greenwood,

British Med. Jour.,
1897, II, p. 1337

A Case of Pulmonary
Carcinoma

For several weeks cough, dyspncea,
swelling of face and neck. Hardly
any air in right apex; tubular breath-
ing left base in front. Improved for
a short time, then increasing dyspncea
and cough, pain down spine. Shortly
before death tubular breathing right
base; cedcema both legs. Duration a
little over 6 months

Griffiths,

Brit. Med. Jour., 1888,

I, p. 647
Sarcoma of the Lung

Cough, emaciation, cyanosis, oedoe-
ma of eyehds, dyspnoea. Absolute dul-
ness, feeble motion and respiration over
left chest. Aspiration negative. Diag-
nosis of malignant tumor of lung made
during Hfe. Duration about one year

Hafner,

Med. Centralblatt,
38, 1852

Cachexia, tumor of right clavicle;
paralysis of right arm; radial pulse
smaller on right than on left side.
Dyspnoea, pain, dry cough, hoarseness,
dulness over upper portion of right
chest; dilated veins of neck and arm

Hanot,

Arch. gen. de Med.,
1877, Vol. I, Ser. 6,
p. 29

Cancer primitif du Pou-
mon et du Mediastin
chez une femme de 78
ana

Always well. Dry cough for long
time, worse for last few months;
dyspnoea, pain in right chest. Alter-
nating diarrhoea and constipation. On
admission cachexia, weakness, dulness
over whole of left chest. In upper
portion distant breathing sounds; in-
creased vocal fremitus; subcrepitant
rales. At base of right lung rales and
some friction with slight dulness.
Heart pushed to the right. Later,
oedcema of feet, dysphagia, delirium.
Death from exhaustion about 3 weeks
after admission

DOUBTFUL

289

Scant, mU'
coid, later
bloody-

Not given

Purulent,
blood-
stained

Mucopuru
lent. No
bacilli

No details

AUTOPSY NOTES

Left lung normal; right
lung a solid tumor with thin
shell of lung tissue outside
Tumor contains some cysts

Entire left lung trans-
formed into tumor, prob-
ably starting from hilus.
Entire mediastinum filled
with tumor; imbedded aor-
tic arch and large vessels

Tumor size of cocoanut
occupying middle and pos-
terior mediastinum and ex-
tending along root into right
lung. All other organs
healthy

Tumor at root of left lung
extending along bronchi and
larger vessels, surrounds and
compresses aorta, pulmon-
ary vessels, and oesophagus.
Compression of left main
bronchus

Effusion in right pleura;
hard lobular tumor in upper
part right lung. Compres-
sion of trachea and superior
cava

Left pleural cavity filled
with yellow serous fluid;
lungs compressed; pleura
red, thickened. Posterior
mediastinum filled with
large, hard, white tumor
containing several soft, al-
most fluctuating foci. Nod-
ules as large as a pigeon's
egg on trachea, directly un-
der aorta; another mass
under root of lung. (Esoph-
agus compressed and adher-
ent to tumor. Root of left
lung surrounded by tumor;
bronchus not compressed.
Tumor in left lung consist-
ing of 6 nodules extending
downward and outward to

METASTASES

Mediasti-
nal and
mesenteric
lymph
nodes, lower
jaw, cranial
bones, and
some verte-
brae

Not given

None

Pleura,
bronchial
glands. No
others

MICEOSCOPE

No data given

Not given

Alveolar
structure
with polyg-
onal cells

As no microscopic
data are given it is
difficult to tell
whether sarcoma or
carcinoma

Probably sarcoma

Possibly carcinoma

290

TABLE III

Harbitz,

Norsk Mag. f. Lae-
gevidenskaben, etc.,
1903, Bd. 1, p. 727

Harris,

Intrathoracic
Growths. St. Bar-
tholomew's Hosp. He
ports. Vol. 28, 1892,
p. 73

Heschl,

Wiener Med. Wo-
chenschr., 1877, No

.. 17, p. 385

Uber ein Cylindrom
der Lunge

Hetpelder,

Arch. gen. de Med.

14, 2d S6rie, 1837,

p. 345
DuCancer des Poumons

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Sick since childhood; more or less
cough. Gradual increase of cough
and dyspnoea. Pain in right chest.
Lymphatic glands of neck swollen.
Sonorous percussion sounds over both
lungs. Prolonged expiration in front
and behind

Pain in left chest; dry cough, in-
creasing dyspnoea and emaciation.
Bulging of left chest ; absence of fremi-
tus; displacement of heart to right.
Aspiration 24 ounces. Pleura opened;
foul discharge for a month. Death

No clinical history

Always well. Attack of pleurisy
that yielded to treatment. Later
inflammatory symptoms in chest —
pain, dry cough. Left chest immov-
able on respiration and dilated. Dul-
ness; no voice or breathing; no heart
sounds, right chest normal. Later
large, hard, nodulated tumor on
anterior surface of left chest. Cyano-
sis; dyspnoea. Still later nodulated
tumors on left clavicle, swelling of
axillary glands; general dropsy

DOUBTFUL

291

AUTOPSY NOTES

smaller nodules. Left lower
lobe catarrhal, colloid pneu-
monia. Right lung soft and
congested

Bloody fluid in pericardial
cavity with beginning mu-
copurulent inflammation of
pericardium. In posterior
mediastinum enlarged lym-
phatic glands, also hard,
grayish, degenerating tu-
mor. Bronchial glands and
glands at root of lung en-
larged. Tumor formation
bronchial mucous mem-
brane. Lungs emphysemat-
ous but otherwise normal

No autopsy

2000 CO. clear serum in
right chest. Tumor occu
pying almost entire right
lower lobe; only small border
of compressed lung tissue on
upper periphery of tumor
Tumor made up of soft and
very hard and cartilaginous
nodules

Numerous tumors on wall
of left chest. Left lung en-
tirely transformed into one
large tumor in which neither
vessels nor bronchi can
be recognized. Left main
bronchus obliterated. Pul-
monary artery and vein ob-
literated, also left pleura.
Superficial tumors commun-
icate with internal tumors
through intercostal spaces

METASTASES

Mediasti-
nal and
bronchial

None

Besides
the axillarj'
glands and
superficial
tumors on
chest, no
other metas-
tases

MICBOSCOPB

Lympho-
sarcoma with
alveoli
clothed with
polygonal
and polsonor-
phous epithe-
lial cells

Superior and
anterior nod-
ules consist of
round and
spindle cells
with abun-
dant hyper-
trophic elastic
fibres. Pos-
teriorly nod
ules contain
several con-
cretions and
some plate-
lets of genu-
ine bone,
masses of
elastic tissue
between
round and
spindle cells
and many pe-
culiar colloid
forms of vari-
ous shapes

No details

Probably carci-
noma of left lung and
pleura

Should be classed
under sarcoma group

Probably sarcoma

292

TABLE III

HODENPTL,

Proceedings N. Y
Path. Soc, 1895, p. 19
New Growths of the
Lung, Mediastinal
and Mesenteric
-Glands, Liver and
Stomach

Hope, J.

London, 1834, p. 45
Principles and Illustra-
tions of Morbid Anat
omy .

Janewat,

Medical Record, 1883,

p. 215
Primary Sarcoma of

Lung

Jakobsohn,

Deutsch. Med. Zeit-
schr., 1897, p. 487

Sarkom der Lungen

Jennings,

Proceedings Path.
Soc. of Dublin, 1867-
68, p. 291

LUNG IN-
VOLVED

Both

clinical symptoms

Fell on left shoulder; soon there-
after lancinating pain in left chest.
Pleuritic effusion of bloody serum;
numerous tappings. Dulness over
left chest in front and behind with
absolute flatness and abolished voice
and breathing in lower portion. Aspi-
ration does not afford relief. Dyspnoea
and suffocation, csdcema of left arm;
anasarca and ascites. Duration about
7 months

10 years before admission strain at
cricket; ever since tenderness on
right chest. On admission tumor of
right chest extending from 4th to 11th
rib; imperfect expansion of right
chest; absolute flatness and absence
of breathing sounds below 5th rib.
Death 10 days after admission.
External tumor noticed 18 months
before admission

Progressive debility, dyspnoea, slight
fever, pain in right side, dyspnoea.
Flatness over half of right lung;
diminished fremitus. Small quantity
bloody fluid in pleura

Syphilis admitted. While carrying
a heavy load of zinc plates on shoulder
up a ladder, suddenly severe cough and
dyspnoea, with much rattling and
wheezing. Was carried home and
since that time intense dyspnoea, im-
paired respiratory motion left chest;
dulness over left chest and bronchial
respiration. Within next week dul-
ness becomes more intense and exten-
sive. Some improvement after 10
mercurial inunctions ; respiration more
normal and patient in every way much
better. Probatory puncture made
and needle penetrates deeply into hard
mass. (Not stated where puncture
was made.) A few drops of milky,
easily coagulating fluid withdrawn in
syringe. This under the microscope
shows numerous small round and
spindle cells. Since then patient feels
fairly well, but has attacks of suffoca-
tion from time to time

Well until close of year, then intense
dyspnoea, cough, slight expectoration.
Pain in right chest; stridulous respi-
ration. Dulness over right chest;
absence of voice and breathing, except
coarse tubular breathing in scapular

DOUBTFUL

293

Bloody

AUTOPSY NOTES

Scant,
grayish

Not bloody

No details

Thin and

scanty.
No haem-
optysis

Left lung almost entirely
converted into a mass of
new growth. Enormously
enlarged mediastinal glands
compressing trachea and
oesophagus. Large mass
above heart, encircling large
vessels. Fracture of a rib
with much callus

Tumor fills entire right
pleural cavity except | of
upper lobe. Lower lobe
flattened and "inextricably
confused with the tumor."
Heart dislocated to left. 8th
and 9th ribs destroyed by
tumor, and through this
space tumor emerges from
chest

Neoplasm in middle and
lower lobe of right lung

METASTASES

Anterior mediastinum
and anterior superior sur-
face of lungs occupied by tu-
mor which absorbed part of
thoracic wall and formed
part of tumor visible during

Liver,
lymph
nodes, and
cardiac end
of stomach;
ulcerated
nodule in
stomach

Upper right
lobe and left
lung

MICROSCOPE

Tracheal,
bronchial
and medias-
tinal lymph
nodes; liver

Mediasti-
nal and ab-
dominal
glands; liver

Typical car-
cinoma in
lung with
well-marked
alveolar struc
ture and epi-
thelial cells.
In IjTnph
nodes and
liver alveolar
structure but
spindle cells

No details

Probably carci-
noma of lung

Insufficient

No details

Probably primary
sarcoma of right lung

In extract neo-
plasm is called "in-
filtrating cancer,"
and description tal-
lies with usual forms
of infiltrating carci-
noma. In title the
tumor is called sar-
coma

Author diagnoses
sarcoma and thinks
it sarcoma of pleura

294

TABLE III

Kempeh,

Trans. Indiana Med.

Soc, 1882, 172-178
Primary Cancer of

Lung

KOEYLINSKI,

Diss. Greifswald,
1904
Uber primare Sar-
kome in der Lunge

KUHN,

.. Diss. Zurich, 1904
Uber maligne Lungen-
geschwulste

Langb, J. C.

Penna. Med. Jour.

Pittsburg, 1903-4,

Vol. XXXIII, p. 202
Four Cases of Malig

nant Disease of the

Lungs

Langstaff,

Medico-Chir. Trans.,
Vol. IX, 1818, p. 295ff

Cases of Fungus Hae-
matodes, Cancer, and
Tuberculated Sar-
coma with Observa-
tions

60 Lataste,

Bull, de la Soc. Anat
3 S., X, p. 767 (after
Szelowski)
Cancer primitif du Pou
mon, etc.

LUNG IN-
VOLVED

L(?)

CLINICAL SYMPTOMS

region. Left side normal. Heart
much more audible on right than on
left side. Impaired mobility of right
chest. Right intercostal spaces oblit-
erated. Under right clavicle _ semi-
globular tumor, tense and elastic. 14
days after admission enlarged gland
above clavicle. Admitted August 28;
died October 5

ChiUs, fever, facial paralysis. Pain

right chest. Extensive dulness

from below upward on right side.

Bulging of intercostal spaces; cedcema

of right hand; enlarged axillary glands

No heredity. Patient was received
into surgical clinic for phlegmon of
penis and scrotum. There were no
lung symptoms; death resulted from
the surgical affection

No heredity. Emaciation, vomit-
ing, absence of free HCl in stomach;
pain in stomach and Liver; dyspnoea;
enlarged liver with palpable tumor

After "cold," cough, pain in chest,
loss of weight for 4 months; then
oedoema of right face, neck, chest,
immensely distended veins. Indurated
glands in neck, axilla and under pec-
torals. Tumor as large as orange
protruded from chest, eroding 3d and
4th ribs. On physical examination
many secondary nodviles in both lungs

Cough, difficult breathing for 2
years. Pain in right chest, intense
dyspncEa, hoarseness, dysphagia. Clini-
cal diagnosis : asthma or phthisis

Always in good health. Month
before admission dizziness and palpi-
tation. Soon after pleuritic effusion,
dyspnoea. Flatness over all of left
chest; dulness over right phest. Loss
of fremitus on left side; increased on
right. Heart dislocated to right.
Congestion of lungs is diagnosed.
No puncture is made, but venesection.
Death in asphyxia

DOUBTFUL

295

Profuse;
not bloody

AUTOPSY NOTES

life. Both pleural layers ad-
herent to diaphragm and
thorax. Substance of right
lung studded with miliary
granules and traversed by
fibrous bands. Left lung
also involved in cancer.
Posterior mediastinum filled
with morbid deposit and
glands

Right lung solidified,
some parts being "cartilag-
inous and greasy," others
"like liver." Bronchial
tubes completely occluded

Tumor size of a small fist
in left lower lobe adherent at
its free surface to the upper
lobe. On section seen to be
composed of 4 smaller nod-
ules

Primary nodule in lung

None made

Almost entire right lung
converted into firm, pulpy
tumor especially at root.
Right main bronchus ulcer-
ated and almost obliterated
by tumor

Serous effusion in left
pleura. Both lungs studded
with nodules size of a cherry.
No tumor anywhere else

METASTASES

Axillary
glands

None

Pericar-
dium, liver,
both pleurae,
bronchial
Ijonph
nodes

Bronchial
glands

None

MICROSCOPE

It is simply
stated that
tumor is
"cancer"

Microscopic
examination
seems to show
fibromyoma.
In epicrisis
author calls
the tumor
' ' fibrosar-

Not given

No details

Encepha-
loid cancer

No secondary
symptoms, no metas-
tases; nothing speaks
for malignant growth

Probably sarcoma

Probably primary
carcinoma of right
main bronchus

Probably sarcoma

296

TABLE III

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Lehlbach,

Trans. Med. Soc. of

N. J., 1870, p. 150
Case of Primary En-

cephaloid Cancer of

Right Lung

LiNDSET,

Proceedings of Arkan-
sas Med. Soc, 1899,
p. 131
An Obscure Case of
Pulmonary Cyst

McAldowie,

Lancet, 1876, II, 570
Cancer of lung in Child

5* Months Old

McPhedran,

Canadian Practi-
tioner and Review,
Toronto, XXV, 1900,
p. 17

Carcinoma of Lung and
Pleura with Occlusion
of Superior Vena
Cava

5^
mos.

Both

Meissner,

Schmidts Jahrbiicher,
1873, Vol. 158, p. 285

Olmeh,

Marseille Med., 1901,
p. 279

Both

Cough, dulness upper portion right
chest in front, bronchial respiration.
Pain, increasing emaciation and
debility; night sweats; intermittent
fever. Left lung normal. Later hard
painful swelling in pectoral muscle over
dull area. Duration about one year

In prison convicted of murder. Nov.
1898 oblong fluctuating tumor over
9th-llth ribs to left of spine. Flat-
ness of left chest anteriorly and pos-
teriorly to 3d rib; also absence of
breathing. Several probatory punc-
tures withdraw nothing but blood.
No fluid in pleura. Exploratory in-
cision made in tumor. Arterial blood
flowed from incision and thoracic
aneurysm was diagnosed. Patient's
appetite good; no loss of flesh or
strength, but rather gain. History
of syphilis, and K I given. Tumor
continued to grow and an enormous
flow of blood followed the introduc-
tion of the smallest needle. Opera-
tive interference followed by enormous
haemorrhage. Death March 1899

No heredity. Normal at birth;
other children healthy. Failed al-
most at once after birth. Short dry
cough; emaciation; feeble breathing;
few fine rales. No dyspnoea. Per-
cussion clear over both lungs

No heredity. Chronic bronchitis
for 16 years. About year before
admission pain in right scapula, arm,
and face. Incipient tuberculosis of
right apex suspected. Severe _ noc-
turnal cough and sweats. Pain in
right chest, weakness, haemoptysis.
Effusion in right pleura; heart dis-
placed. Several aspirations of clear
serum, but no change in dulness.
Increasing dyspnoea and weakness;
cyanosis of face, arms, chest, and hands;
cyanosis to costal margin, but not
below. No respiratory motion right
chest; no fremitus^ below right 2d
rib; flatness and diminished respira-
tion. Duration about 2 years

Pain for 3 months with increasing
debility, cough, swelling of limbs;
intense dyspnoea; rapid enlargement
of liver. Duration about 5 months

Admitted moribund; died within a
few hours. No history. Flatness and
amphoric breathing at left apex.

DOUBTFUL

297

SPUTUM

AUTOPSY NOTES

METASTASES

MICBOSCOPE

EEMARKS

Streaked

Almost entire right lung

No details

Nothing said about

with

except small area at base

other organs

blood.

and apex converted into en-

Later

cephaloid mass. 3d, 4th,

purely

and 5th ribs entirely de-

mucoid

stroyed

No details

Large tumor filling whole
left chest and pushing dia-
phragm downward, heart to
right and whole left lung
above 3d rib. Erosion of
3 ribs where tumor had
pressed out. Cystic portion
of tumor had been cut off by
Hgatures. On section tumor
showed two kinds of tissue:
the outer, pinkish, glisten-
ing; inner, medullary; about
1 of bulk of tumor compact
fibrous substance, resem-
bling decomposing brain tis-
sue

No details

Probably sarcoma

No details

Both lungs studded with
hard white nodules; hard
mass at root of left lung
extending through entire
thickness of lung. Pulmon-
ary tissue around nodules
quite normal. Pleurae
thickened and adherent

Bronchial
glands

None

Bloody; no

Nodules in both lungs,

No metas-

Epithelial

Probably primary

tubercle

right pleura, and diaphragm

tases in ab-

cells, prob-

in pleura. I. A.

bacilli

dominal or-
gans

ably from en-
dothelium of
lymph ves-
sels; colum-
nar cells and
basement
membrane,
polymor-
phous cells

No details

Both lungs studded with
miliary nodules. In right
lung tumor size of cherry,
soft, yellowish white with
hffimorrhagic centre

Liver,
spleen, kid-
neys

No details

Cheesy masses in right

Lymph

Dense, fi-

Author is in doubt

lung. Miliary tubercles

nodes of left

brous, very

whether it is carci-

throughout both lungs.

bilus

vascular

noma or sarcoma or

298

TABLE III

Tuberculose et Cancer
primitif du Poumon

OSBOHNE, O. T.

Yale Med. Jour., Vol
IX, 1902, p. 50

A Case of Primary Car-
cinoma of the Lung

Peacock,

London Path. Soc,
XIV, p. 40.

Carcinoma of Left
Lung with Secondary
Deposits in Heart,
Kidneys, Suprarenals,
etc.

Peacock,

Trans. London Path.
Soc, IX, 1859

Pepphb,

Trans. College of
Physicians, Penna.
1850-53

POKIER ET NeUVILLE,

Jour, des Coimais-
sances Med. prat. T. I.
1833-34, p. 104
D6g6nerescence squir-
rheuse de la totality
du Poumon droit,
Phthysie consecutive.

LUNG IN-
VOLVED

Both

clinical symptoms

Rales throughout both lungs,
fever

_ Always healthy. Recently palpita-
tion and breathlessness. 2 months
before admission some trouble with
left lung had been found. On admis-
sion absolute flatness of entire chest
with absence of voice and breathing
and loss of fremitus except at very
apex. At probatory puncture needle
enters hard mass. Clinical diagnosis:
tumor. Dry harassing cough, but
never pain. Nodule in abdomen.
Later paralysis of left recurrent.
Dysphagia. Asthmatic attacks with
profuse bronchial secretion from right
lung. Centre of tumor begins to
break down. Died about a month
after first visit

Cough, dulness over all of left
chest. Almost entire absence of breath-
ing sounds; feeble vocal vibration.
Heart displaced to right. Swelling
of lower costal cartilages; enlarge-
ment submaxillary glands. Death
from exhaustion. No bronzing, but
dingy complexion. Duration about
8 months

Disease commenced with hgemoptysis.
Later larger and smaller masses were
ejected with cough. Dulness, bron-
chial respiration; deficient breathing;
crepitation over varying areas in both
lungs. Later increasing dyspnoea.
Diarrhoea. Pain in chest, especially left
side. General anasarca with normal
urine; later anasarca disappeared ex-
cept in face. Duration about 4 months

Pain, swelling of right arm, chest,
and mamma. Feeble pulse. Flatness
over entire right chest; bronchial
breathing; no rales. Right chest
distended; dyspnoea, slight dysphagia.
No cough

Grandfather died of cancer. Dry
cough for several years. When
lifting a heavy weight felt sharp pain
in right side. Some weeks later tumor
in right side, where pain had been.
On examination dry cough, tumor size
of filbert adhering to 6th rib. Dulness
over right chest. No fever. 8 months

DOUBTFUL

299

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMARKS

spleen, and liver. Left up-

stroma en-

a combination

per lobe transformed into

closing alve-

both

dense grayish tumor con-

oli filled with

taining small cavities

partially nec-
rotic epithe-
lial cells

Occasion-

Whole of left lung shrunk-

Both kid-

No micro-

ally

en into cancerous mass with

neys and

scopic exami-

bloody,

greatest consolidation at

skin

nation made

no tuber-

root. Base of heart at-

cle bacilli.

tached to tumor, also chest

Numer-

walls; broken down in cen-

ous flat

tre. Right lung healthy

epithelial

cells

thought

to be al-

veolar

cells

Bloody,

Tumor infiltration of al-

Various

No details

Probably sarcoma

large

most all of left lung; bron-

lymph

masses of

chiectatic cavities

nodes.

pus

heart, peri-
and endo-
cardium.
Complete
tumor de-
generation
of both su-
prarenals

Bloody and

Tumor masses in both

None in

Both tu-

Probably sarcoma

purulent.

lungs with numerous cavi-

other organs

mors and the

masses

ties containing pus and nec-

coughed-up

ejected

rotic material

rnaterial con-
sist of spindle
and round
cells

None

Tumor masses through-

Bronchial

Not stated

Some doubt

out right lung. In medi-

and mesen-

whether primary

astinum a large tumor sur-

teric lymph

lung

rounding aorta and com-

nodes, head

pressing lower cava, pul-

of pancreas.

monary artery, trachea, and

and ovaries

oesophagus

No details

Tumor occupied whole of
right chest and part of left,
adherent to pericardium,
loft costal cartilages, ster-
num, right ribs, and verte-
bral column ; around 6th to
8th ribs it penetrates to

Probably
in abdomen.
Statements
not very
clear

Not given

subcutis, forming there a

300

TABLE III

LUNG IN-

NO.

AUTHOR

SEX

AGE

VOLVED

CLINICAL SYMPTOMS

Mort aprls dix-neuf

later diagnosis of empyema was made,

mois de Maladie; N6-

but no trace of liquid was found on

cropsie

operation. After 19 months of sick-
ness: extreme emaciation, chest more
distended on right than on left, hard
nodulated tumor under right breast.
Dulness over right chest with absence
of respiration. Tumor in abdomen
attributed to liver. CEdcema of lower
limbs; intense dyspnoea

Powell,

Middlesex Hospital
Reports, 1892. Lon-
don, 1894, p. 87

Malignant Disease In-
vading Right Lung.
Gastric Ulcer

Sick for about a year with gastric
symptoms. Cough for about 3 years;
lately worse. _ In bed for 19 weeks
before admission with dyspnoea and
wasting. On admission oedoema of
right arm, dilated veins of right chest.
Impaired respiratory motion. Dul-
ness and flatness over most of right
chest. Feeble or bronchial breathing.
Heart beyond nipple line. No change
in physical symptoms until death.
Duration probably several years

Powell,

London Med. Gaz.,
1850,XI, pp. 1029,31

Severe pain in right chest. Right
lung completely dull; feeble breathing
sounds. Slight cough

Pbevost,

Compt. rend. Soc. de
Biol., 1875-76, II, 175
-180

Cachexia. Indefinite dyspeptic
symptoms. Frequent tappings for
hsemorrhagic pleural effusion. Dysp-
noea

Phtjdhomme,

Union Med. du Nord-

Est, Reims, 1903, p.

213
Cancer lobaire primitif

du Poumon Gauche

No heredity. For 5 months rapid
decline of strength. Slight attacks
of cough. Flatness on left anterior
chest from top to below left mammilla;
behind about 2 fingers below spine of
scapula. Over all this area absence
of voice and breathing. _ No rales.
Dyspnoea on slight exertion; some
hoarseness. Later oedcema of left arm.
Heart displaced to right. Increasing
dyspnoea and emaciation. CEdcema of
left lung. Aspiration 1000 c.c. yellow
serum. CEdoema improved, but no
change in physical signs. Cough with
pain in shoulder. Death about 2
mouths after admission

QUAIN,

Trans. London Path.
Soc, 1857, VII

Symptoms of tuberculosis — cough,
night sweats, cachexia, dyspnoea,
hoarseness, dysphagia, pain in left
chest. Dulness over left apex, dimin-
ished breathing; rales

Robertson,

Glasgow Med. Jour.,

No heredity; no syphilis. Cough,
pain across chest; cyanosis, dyspnoea,

DOUBTFUL

301

No details

large, white, nodulated lar
daceous mass. Tumor had 3
cavities containing serum
and pus. At upper and po&
terior part of tumor a thin
layer of lung tissue; remain-
der all scirrhous. Upper
lobe right lung compressed
by tumor. Heart displaced
to left. Albuminous mass
in abdomen

It is simply stated malig-
nant growth invading right
lung; old gastric ulcer. No
other details given

Scant, haem-
optysis

Yellow, al-
bumin-
ous

Scanty
showed
nothing
charac-
teristic

Scant,
mucoid.
Hffimop-
tysis

Mucopuru-
lent, oc-

AUTOPST NOTES

Slight effusion in pleura
Right lung almost complete-
ly transformed into solid
cartilaginous tumor

Tumor with cavity at
base of right lung

Entire upper left lobe in
vaded by cancerous mass
broken down and forming
cavities containing creamy
matter

Large tumor between
apex of left lung and arch of
aorta. Compression of
oesophagus and left bron
chus. Mass between tra-
chea and oesophagus pressing
on recurrent laryngeal. Left
lower lobe infiltrated with
soft tumor

Simply stated that "tu-
mor was found to be a lym-

MBTA8TA8E3

No details

Right lung
and pleura

Cancerous
nodules in
mediasti-
num ex-
tending to
pericardium
compressing
aorta and
pulmonary
artery. No
other metas
tases

Bronchial
and medias-
tinal lymph
nodes

No details

MICROSCOPE

No details

None made

No details

Possibly sarcoma

302

TABLE III

1889, Vol. XXXI, p.
454
A Case of Tumor of the
Lung

Rob,

Lancet, 1866, II, 723

ROTTMANN,

Diss. Wiirzburg, 1898
Uber primares Lun-
gencarcinom

Russell,

London Med. Times
and Gaz., 1864, II, p.
278

Rttssell,

Lancet, 1869, I, 814

See Germain,

Revue Med., 1881,

XXXI, 121-127

L'Union Med.
Diagnostic de Cancer

pulmonaire

SiLVA,

Gaz. degli Ospidali e
delle cliniche Milano,
XXII, 1902, Serie II,
p. 1236
Sarcoma primario del
Polmone

LTJNG IN-
VOLVED

CLINICAL SYMPTOMS

hoarseness. Dulness over upper por-
tion right lung; increased vocal fremi-
tus; prolonged expiration; all kinds
of rales. No fever. Enlarged and
tortuous veins of abdomen and chest.
Apex beat dislocated to left. Heart
sounds heard distinctly over dull
area. Rapid increase of dulness and
some bulging of right chest wall.
(Edcema of hands; sHght exophthahnus
of right eye. Duration about 4
months

Cough, dyspnoea, pain in chest.
Flatness and harsh respiration. Right
lung normal. Symptoms of peri-
carditis and pneumonia, then small-
pox and death

Syphilis. Complained of lungs for
2 years. Emaciation and debility.
Spontaneous fracture of right thigh.
Flatness at right base posteriorly,
slight bulging of chest, diminished
voice and breathing. Cough

Extreme dyspnoea. Flatness over
left chest. Respiratory immobUity;
intercostal spaces retracted. Explo-
ratory puncture, some blood. Lower
lobe cleared up before death

Distress after eating, frequent vomit-
ing, cough, dyspnoea, palpitation. Pain
in left shoulder, chest, and arm.
Impaired respiratory motion. Dul-
ness at apex with absent breathing and
voice. Effusion in left chest

Pain, dyspnoea. Flatness and ab-
sence of voice and breathing over left
chest. Small hard lymph nodes
above clavicle

No heredity. 7 years ago acute pul-
monary disease with cough. For one
month dry cough, and severe pain
radiating to both lower limbs and left
shoulder; also behind sternum. No
fever. Obstinate constipation; ano-
rexia. Impaired expansion of left
chest; loss of voice and breathing.
Complete flatness. Emphysema of
right lung. Two punctures withdraw
small amount of bloody serum, but
needle enters into hard tumor mass.
Slight fever and much intestinal dis-
turbance. Death after 3 months in
hospital

DOUBTFUL

303

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMARKS

casion-

phadenoma probably origi-

ally

nating in mediastinum,

tinged

some portions of it having

with

caseated and broken down"

blood

One hfiem-

At base of left lung hard

Right lung

No details

Possibly sarcoma

optysis

cartilaginous tumor, com-
pressing bronchus and
oesophagus and extending to
left auricle. Bronchiectatic
cavities throughout left lung

Abundant

Large tumor in right

Bronchial

Partly car-

lower lobe, partially necrotic

lymph

cinoma, part-

and purulent. Lower and

nodes and

ly sarcoma

middle lobes diffusely infil-

right femur.

trated. Left lung normal

No others

No details

Hilus of left lung sur-
rounded by tumor envelop-
ing bronchus and large ves-
sels. Infiltration of upper
lobe

Left bron-
chial lymph
nodes only

No details

Bloody

Cancerous nodules around

Bronchial

No details

root involving posterior up-

lymph

per left lobe, extending into

nodes

left auricle. Tumor prolif-

erates along bronchial tract.

Left bronchus and pulmo-

nary veins compressed

Pus and

No autopsy

Axillary

No details

There was no au-

blood

and supra-
clavicular
lymph
nodes

topsy, but the physi-
cal signs and sputum
as well as absence of
fever and rapid ag-
gravation, all point to
tumor of lung

No details

Left lung shrunken and

Liver, su-

No details

Probably carci-

adherent, containing tumor

prarenals.

noma

size of melon, hard and fi-

ribs, verte-

brous and adherent to peri-

brae

cardium. Pulmonary artery

compressed. In interior of

tumor numerous bronchi-

ectatic cavities filled with

purulent secretion. Lung

tissue surrounding tumor

atelectatic and cedcematous

304

TABLE ni

NO.

AUTHOR

SEX

AGE

LTTNG IN-
VOLVED

CLINICAL SYMPTOMS

Sims,

Medico-Chirurg.
Trans., Vol. XVIII,
London, 1833, p. 281

On Malignant Tumors
connected with the
Heart and Lungs

For about a year before admission
various haemoptyses, sometimes pro-
fuse ; dyspnoea and severe oppression.
Later harassing cough. Dulness on
right chest anteriorly; absent breath-
ing. Dilated jugular veins; sweUing
of head and neck. Diagnosis made
during life

Log. cit.

Hemiplegia for about 12 months.
Cough and other pulmonary symptoms
for several years. Brain sjrmptoms
predominated and no attention was
paid to lungs

Spabks,

Lancet, 1871, II, 13
Primary Cancer of the

Lungs

Diagnosis of pleuro-pneumonia. No
other clinical data

Steell,

Lancet, 1894, 1, p. 388
A Case of Tumor of the

Lung

No previous illness. No symptoms
pointing to lungs. Routine examina-
tion showed dulness over whole left
chest with loss of fremitus and absence
of breathing over lower part chest.
Slight cough. Later high fever and
pericardial friction. Clinical diag-
nosis: fibroid phthisis

Stokes,

New Syd. Soc. Ed.,

1882, p. 386
Diseases of the Chest

Some pains in right side; cough,
hoarseness, dyspnoea; cedoema of face
and neck. Dulness over entire right
chest; gradually loss of voice and
breathing sounds. Heart sounds
heard all over right chest. Later en-
larged liver and jaundice. Tumors
appear on forehead, lower jaw, and
lumbar spine. Diagnosis of tumor
made during life

Log. cit.

Pain in left side, dyspnoea, dysphagia.
Later left hemiplegia and epileptiform
attacks. Left radial smaller than
right. Flatness over entire upper
left chest; feeble breathing. Dia-
stolic pulsation and bellows murmur
in upper sternal and subclavicular
regions; nevertheless tumor and not
aneurysm was diagnosed

Stokes,
Loc. cit

After a cold, cough and pain in right
side. Cachexia; right side tender to
touch. Tympanitic percussion note;
cavernous breathing; tympanitic note
later replaced by flatness. Night
sweats, diarrhoea, dyspnoea; oedcemaof
face and left hand. Duration 5 to
6 months. Diagnosis made during

life

DOUBTFUL

305

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

BEMAEKS

Mucoid,

Solid tumor probably

Bronchial

No details

Possibly carcinoma

haemop-

starting from hilus of right

lymph

of bronchial origin

tysis

lung, involving greater part
of right chest and compress-
ing large vessels, trachea,
and right main bronchus.
Bronchiectatic cavities in
tumor. Upper cava in-
volved

nodes and
heart

No details

Upper lobe of left lung
contains tumor size of a
small orange of medullary
character. Traces of chronic
pneumonia and solid gray
hepatization, also a few
patches resembling gangrene

None men-
tioned

No details

Large nodulated "en-
cephaloid" tumor in lower
left lobe infiltrating dia-
phragm and pleura. Heart
displaced to right

Right lung,
both pleurae

No details

Scant,

Effusion in left chest. Left

No details

Insufficient;

Possibly carcinoma

slightly

lung compressed ; upper lobe

tumor is

bloody

infiltrated with soft, white

called lym-

early in

new growth. Bronchus of

pho-sarcoma

disease

lower lobe almost entirely
obstructed by tumor. Sup-
purative pneumonia lower
left lobe

Scant, occa-

Very large tumor in place

Mesenteric

No details

Probably sarcoma

sionally

of right lung of which a com-

and retro-

bloody

pressed portion is found over
posterior surface of tumor.
Tumor contains cysts and
envelops trachea, large ves-
sels, and pericardium. Right
main bronchus compressed
and obstructed

peritoneal
glands com-
pressing
common
bile duct

Bloody

Large tumor from root to

No details

Possibly bronchial

apex in left lung; gangre-

carcinoma

nous cavity in lower lobe

Copious,

Entire lung converted in-

No details

Probably bronchial

frequent-

to tumor containing bron-

carcinoma

ly bloody

chiectatic cavities

306

TABLE III

NO.

AUTHOR

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Loc. CIT.

Cough, dyspnoea, pain. Increasing
dulness over right lung. Dilatation of
veins. Feeble respiration. Increas-
ing volume of chest. CEdcsma of face
and chest. A month later some im-
provement; retraction of right chest.
Clinical diagnosis: empyema and ma-
lignant tumor

Stone,

Clinical Cases Med.

& Surg., New York,

1878. p. 55
Tumors in the Lungs,

etc.

Both

Always thin and feeble. Some weeks
before death difficult breathing, which
became "asthmatic." Extreme dysp-
noea. Right lung solid on percussion ;
bronchial respiration. Flatness oyer
left lung; mostly bronchial respira-
tion; some cough. Clinical diagnosis:
thymus asthma or pneumonia, but as
there was no fever the latter was
doubted

Strbhlin,

Diss. Miinchen, 1904
Primares Endotheliom

eines Hauptbronchus

uad der Lunge

Practically moribund on admission.
Intense dyspnoea, cough. Suffering
more or less for a long time, but more
in the last 2 months. Owing to pa-
tient's condition examination was very
imperfect. Emphysema of both lungs;
loud tracheal rattle, diffuse rales over
both lungs. Clinical diagnosis: myo-
degeneration of heart, bronchitis,
arteriosclerosis, emphysema

Suzanne,

Journ. de Med. de
Bordeaux, 1883-4,
XIII, p. 573

Cachexia, palpitation. CEdcema of
right face, arm, and trunk. Dilated
veins. Tumor in left axilla and over
clavicle. Right chest flatness; cavern-
ous breathing; imperfect respiratory
motion

TiNNISWOOD,

London & Edinburgh
Monthly Journal of
Med. Science, 1844,
p. 550
Lardaceous Schirrhoma
of the Lung Involving
the First Rib, Clavi-
cle, etc.

For over a year cough, dyspnoea, and
occasional hsemoptysis. _Large_ hard
tumor arising frorn 1st right rib and
clavicle. Emaciation. Dulness over
right chest; diminished voice and
breathing. Dilatation of veins of neck
and chest. CEdoema of right arm with
pain and numbness. Fracture of
clavicle. Duration of disease about a
year and a half

Trotter,

British Med. Jour.,
1871, II, p. 583

Dulness below right clavicle with
fine rales. Later signs of cavity. Still
later abdominal pain, fullness and tym-
panites

DOUBTFUL

307

BPUTUM

AUTOPST NOTES

METASTASES

MICROSCOPE

EEMABKS

Bloody and

Pus in right pleura; right

No details

"black

lung converted into large tu-

currant

mor; bronchiectases

jelly"

No details

Thjonua pormal. Tumors
in both lungs which com-
press lung tissue ; most of
the tumor subpleural, al-
though some imbedded in
lung. Tumor resembles
Malaga grapes in shape and
size; white, not fatty

No details

Autopsy incom-
plete, but neverthe-
less likely that tumor
is primary in lungs.
Probably sarcoma

Bloody

Large quantity of turbid

Both kid-

Fine fibrous

May be classed as

serum in left pleura; right

neys

stroma con-

carcinoma or endo-

pleura obliterated. Pri-

taining nu-

thelioma. The

mary endothelioma of right

merous

branching and com-

bronchus with extension in-

branching

municating alveoli,

to lung. Purulent bronchi-

and commu-

probably lymphatics,

tis. Bronchiectatic dilata-

nicating alve-

point to endothelioma

tion. Purulent degenera-

oli filled with

tion of peribronchial lymph

small, closely

nodes Pericesophageal ab-

packed cells

scess. Upper and middle

like endothe-

right lobes matted together.

lial cells ; here

Bronchiectatic cavity, size

and there

of hen's egg with numerous

concentric

small gray nodules in its wall ,

layers of cells.

communicates with dilated

Much necro-

bronchus. Bronchi filled and

sis

obstructed by tumor masses

Some haem-

Fluid in left chest. Heart

Liver, mes-

No details

optysis

displaced to left. Large
vessels compressed. Tumor
in upper cava. Greater part
of lung converted into tu-
mor connected with tumor
in mediastinum

enteric
glands

Mucous,

Right upper lobe com-

No details

Probably primary

often

pletely transformed into tu-

sarcoma of right up-

tinged

mor which extends into mid-

per lobe

with

dle lobe. Tumor came up

blood

from lung into superior tho-
racic opening and involved
clavicle and ribs. Autopsy
not complete

Haemopty-

Right upper lobe almost

Right lung,

No details

sis

entirely destroyed by soft
tumor, degenerated and
forming a cavity

left lung,
kidneys,
right 5th
rib, 4th left
rib

308

TABLE III

Von Pflug, H.,
.. Diss. Munchen, 1904
ijber primare Lungen-
geschwiilste

Van Gieson,

Medical Record, 1879,

XVI, p. 495
Cancer of Lung

WaCHSMANN & POLLAK,

New York Med. Rec-
ord, Nov., 1904
Three Cases of Primary
Malignant Tumor of
the Lung

90 Log. cit.

liUNG IN-
VOLVED

Wacqttez,

Journ. des Sciences
Med. de Lille, Xlle
Ann6e (Tome 1, 1889)
p. 393

Cancer primitif du Pou-

CLINICAL SYMPTOMS

For several years cough; later pain
in left chest, increasing cough and some
fever. Dulness over whole of left
chest; at base posteriorly flatness.
Over dull area loud bronchial respira-
tion, fine mucous rales. Probatory
puncture: negative. Tumor suspect-
ed. Slight dysphagia. Sudden death
through profuse haemoptysis

No heredity. Severe pain in left chest;
dry cough. Left arm cedcematous.
Cyanosis; dulness below left clavicle.
Left chest 1 2 inches larger in circumfer-
ence. Absence of respiratory sounds
over all of left chest. Exploratory
puncture negative. Exophthalmus left
eye; pupils dilated. Severe dyspncea

Commenced with pain in left shoul-
der and cough; hoarseness. Flatness
over left upper lobe and at base; dimin-
ished breathing sounds. Bulging of
left thorax. Clubbed fingers. Peri-
osteal tumor over left temporal bone

Cough, pain in left chest, impaired
respiratory motion and flatness from
1st rib to base. No respiratory sounds
in left axillary line or in back. Paraly-
sis of left vocal cord

No heredity; no previous illness.
Sudden expectoration of clotted blood
without apparent cause. Recurrence
shortly with considerable haemoptysis.
Some sweating and fever. Later se-
vere pain along spinal column and at
base of thorax ; excessively sensitive to
touch. Cough very painful. _ Increas-
ing dyspnoea. On examination right
lung normal. Left lung: dulness an-
teriorly with absence of breathing and
diminished voice. Puncture: bloody
effusion containing many epithelial
cells with granular fatty degeneration.
No relief after puncture. Death after
about 6 days in hospital. Duration
from first haemorrhage about 7 months

DOUBTFUL

309

SPUTUM

AUTOPSY NOTES

METASTASES

MICHOSCOPE

EEMAHKS

At first

In place of lymph nodes

Bronchial

Fibrous

Author himself

scant,

at bifurcation, a large encap-

lymph

stroma con-

considers it not abso-

later

sulated tumor, perforating

nodes

taining nu-

lutely certain whether

into oesophagus and extend-

merous com-

cells should be

abun-

ing into left main bronchus

municating

classed as epithelial

dant.

and causing extensive ulcer-

cavities lined

or endothelial or the

Shortly

ation. Erosion of large

or completely

tumor as endotheli-

before

branch of left pulmonary ar-

filled with flat

oma or carcinoma

death, no

tery. Chronic inflamma-

endothelial-

sputum.

tion of left lung; numerous

like cells

Occasion-

bronchiectases

tending to

ally slight

necrosis and

mixture

often ar-

of blood.

ranged in

No tuber-

successive

cle bacilli,

layers

no tumor

cells

None

Bloody serum in left
pleura. Hard white neo-
plasm involves nearly whole
of left lung which is adher-
ent to chest wall and peri-
cardium. Tumor in apex of
right lung

_ Pericar-
dium, right
lung, liver,
sternocla-
vicular ar-
ticulation

No details

Possibly sarcoma

No blood,

Incomplete details

Heart, liver.

No details

Probably carci-

no tuber-

ribs, kid-

noma

cle ba-

neys, clavi-

cilli. CeUs

cles, skull.

which re-

suprarenals.

semble

mesenteric,

cancer

retroperi-

cells

toneal, and
regionary
lymph nodes

Profuse,

Entire left lung taken up

Lymph

No details

Probably epitheli-

greenish,

by soft white neoplasm;

nodes, liver.

oma

occasion-

compression of oesophagus

pericardium,

ally

and trachea; hsemorrhagic

pleura

bloody

effusion in pericardium.
Broncho-pneumonia right
upper lobe

Bloody,

Bloody effusion left

Right lung

No details

Probably carci-

frequent-

pleura. Upper left lobe solid

and left su-

noma

ly cur-

grayish mass of encephaloid

prarenal

rant jelly

tumor; softening in central
portion. Bronchi permea-
ble to centre of neoplasm
where they become replaced
with neoplasm

310

TABLE III

Waldenstrom, J. A.

Deutsche Klinik, 1874

No. 22, p. 169
Cancer Pulmonum

Waters,

British Med.
1886, I, 335

Jour.,

Weichselbattm,
Virchows Archiv.,
LXXXV, 1881,p.559

Papillares Adeno-sar-
kom der Lunge

White,

Dublin Quarterly
Journ. of Medical
Science, 1865,
XXXIX, 219-222

Williams,

Lancet, 1878, II, 732
Cancer of Lung and

Pleuro-pneumonia

Wilson,

Edin. Med. Jour., 1857

Woodman, Bathurst,
Med. Times & Gaz.,
London, 1876, I, p.
411

Case of Encephaloid
Cancer of Bronchial
Glands and Left Lung

Not
stated

lung in-
volved

Not
stated

CLINICAL symptoms

Anjemia, dyspnoea ; dulness and harsh
respiration over left base ; sibilant rales.
No other signs on lungs or other organs.
CUnical explanation of the dyspnoea:
emphysema, although no signs of this.
Rapid increase of dyspnoea; general
bronchitis with abundant secretion.
Broncho-pneumonia ; death

Dyspnoea; dulness over whole right
chest; impaired respiratory motion,
faint breathing and fremitus. 22
ounces dark fluid removed by aspira-
tion; physical signs remain unchanged

Clinical diagnosis: bronchiectases
and effusion into right pleura

Pain; slight dulness below left
clavicle; in some parts right lung total
absence of breathing; dulness over en-
tire lower posterior portion right lung.
Dysphagia, hectic fever. Effusion in
right chest

Pain in left chest, increasing dyspnoea
and emaciation ; cough. Dulness at base
of left lung. Diminished respiration,
but increased vocal fremitus; subse-
quently complete absence of breathing
soimds. Dysphagia. Liver enlarged

Symptoms of pleurisy. Dyspnoea,
cachexia. Duration 6 months

For 10 months bronchitis and loss of
wei'ght. On admission pain in left
side and left arm. Dulness over left
chest, bronchial breathing, absence of
fremitus. Two months later a hard
nodule appeared under upper border
of left trapezius. Two months later
enlargement of left axillary glands on
mass on left side of neck

DOUBTFUL

311

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMARKS

No details

Simply said to be primary
cancer of the lung

No details

Scant, rust

Malignant disease of right

Pericar-

No details

Doubtful whether

colored

pleura involving right lung
along septa

dium, dia-
phragm,
large and
small omen-
tum

primary in lung

No details

Small spherical tumor

No details

Multitudeof

Author calls the tu-

near hilus of right lower lobe

yiUi, the bod-
ies of which
are made up
of round and
spindle-
shaped cells
covered with
cylindrical
epithelium.
Glandular
structures
lined with
cylindrical,
sometimes
with ciliated
epithelium
also found

mor a papillary ade-
no-sarcoma

Bloody, ex-

At root of right lung a

No details

pectora-

large tumor extending into

tion of

lower lobe; posterior medi-

"fleshy-

astinum filled; large en-

looking

cephaloid mass projecting

masses"

into pericardium. (Esopha-
gus compressed

Rusty

Large nodular tumor at
root of left lung, penetrating
and nearly obliterating left
bronchus and invading
lower portion of lung

None

No details

Haemopty-

Fluid in left pleura. Sev-

No details

sis

eral nodules in upper part
left lung, especially along
bronchi

Elastic fi-

Tumor involving upper |

Right

No details

bres and

of left lung and connecting

lung, heart,

pus cells.

with mass in neck. Infil-

iver

No tumor

tration extended to mucous

elements

membrane of left main bron-
chus almost completely ob-
structing it. Bronchiec-
tatic cavities base of left
lung

312

TABLE III

NO.

AUTHOB

SEX

AGE

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Yeo, J. Burnet,
British Med. Jour.,
March 13, 1874, p.
342

A Case of Mediastinal
Cancerous Tumor
Leading to Occlusion
of the Right Bron-
chus, etc.

Cancer and tuberculosis in family
history. Had lues 20 years ago. Six
months previous to admission bron-
chitis, chills, pain in right side. Pleu-
ritic exudate which was entirely ab-
sorbed within a few weeks. On ad-
mission cachexia, heart pushed to right.
Dulness all over right chest and feeble
breathing

DOUBTFUL

313

AUTOPSY NOTES

METASTASES

MICBOSCOPB

No details Tiunor size of an orange
in anterior and posterior
mediastinum, hard, whitish
extending into right bron-
chus almost entirely occlud
ing it

Nodules
in right up-
per lobe

Medullary
cancer with
much con-
nective tissue
and charac-
teristic cells
with large
nuclei

Probably primary
in right bronchus, and
the tumor in anterior
and posterior medi-
astinum a secondary
inflammation of the
lymph nodes. I. A.

314

TABLE IV

BOEHIS,

Arbeiten aus dem Path
Anat. Institut zu Tu-
bingen (Baumgarten)
..Vol. VI, Ht. 2, p. 539
(jber primares Cho-
rionepitheliom der
Lunge

Briese,

Beitrage zur wisseu'

schaft. Med. Festschr

etc.
Braunschweig, 1897,

p. 191
Ein Fall von metastasi-

renden Lungenendo

theliom

Bbunet,

Bull. Soc. d'anat. et de

Physiol, de

Bordeaux, Vol. XII

1891, p. 115
Cancer du Poumon

Charteris, M.
Lancet, 1874, 1, p. 126

On Intrathoracic Can-
cer

LUNG IN-
VOLVED

CLINICAL SYMPTOMS

Married at 22; 4 children. Last
childbirth 14 months before admission
to the hospital. A few weeks before
admission cough, expectoration, night
sweats, pain in right chest. On ad-
mission dulness at apex of right lung;
flatness over remainder of lung, bron-
chial breathing, numerous friction
rales. Left lung normal. Later signs
of effusion in right pleura. Tappings
withdraw clear yellow serum. Later
several abundant hsemoptyses. Death
2§ months after admission

No heredity. Pleurisy on right side
18 years ago. Since then cough, ex-
pectoration occasionally very abund-
ant; once haemoptysis. For 2 years,
after attack of influenza, more cough,
pain in chest, progressive loss of weight.
Later severe intercostal neuralgia on
right side. Dulness and diminished
respiration, loss of fremitus over all of
left upper lobe. A few weeks before
death nodules from the size of a hazel
nut to that of a hen's egg in skin of
abdomen and leg, which when incised
show a viscid fluid. Death in extreme
marasmus

Four years before admission ampu-
tation of right leg at thigh for tumor.
One month before admission violent
chiUs, harassing dry cough, intense
dyspnoea. Right chest bulging. Flat-
ness from angle of scapula to base; in
front from infraclavicular fossa to base.
Intercostal muscles do not contract.
Respiration feeble, distant. Marked
segophony. Nothing on left chest.
Puncture, 600 c.c. bloody serum; flat-
ness not diminished. Gradually all
symptoms increase; cedoema. Several
punctures made and after the last de-
cided improvement, dyspncEa better,
cough not so harassing; respiration
on right chest almost normal; some
pleuritic friction. After a few days
return of all symptoms; intense dysp-
noea, sibilant rales, failing appetite and
fever. Severe pain in back of chest.
Repeated punctures, always bloody
serum. Death about 2 months after
admission

Pleurisy 5 years previously. 11
weeks before admission caught cold,
followed by anorexia, cough, night
sweats; hsemoptysis 3 days before ad-
mission, when became hoarse and tu-
mor appeared on right side of neck.
On admission dyspnoea, pain in epigas-
trium, and vomiting. Dulness over
lower half of right chest in front and

MISCELLANEOUS

315

SPUTUM

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMARKS

Greenish,

Bloody, turbid fluid in

Both lungs.

Typical

Clinical diagnosis

mucoid,

left pleura. Nearly whole

None in

chorion epi-

was uncertain though

no tuber-

of right lung occupied by

lymph

thelioma

inclined to tuberculo-

cle bacilli.

large tumor besides a num-

nodes.

sis. At the autopsy

Haem-

ber of smaller nodules. The

Haemor-

no definite diagnosis

optysis

large tumor contains hsem-

rhagic focus

could be made. Mi-

orrhagic and necrotic areas.

in right

croscope alone gave

Tumor penetrates into up-

broad liga-

the proper diagnosis

per cava and extends up-

ment

ward into vein

Tenacious,

Cavity size of fist in lower

Skin, liver,

Endothe-

Author gives many

contains

part of left upper lobe, filled

kidneys.

lioma. Mu-

reasons in detail why

elastic fi-

with cheesy masses and hav-

left psoas.

coid degener-

he has classed this

bres. No

ing hard, irregularly pro-

lumbar, and

ation of cells.

tumor as epithelioma

tubercle

truding waUs

11th and

Metastases

and not carcinoma

bacilli.

12th tho-

are all cystic

Haemop-

racic verte-

and contain

tysis

brae

viscid, tena-
cious, clear
mucus

Abundant,

Whole of right lung trans-

Large sec-

Not given

Probably sarcoma.

green

formed into an encephaloid

ondary tu-

Remarkable for

irregular mass without any

mor in liver

length of time, 4

trace of lung tissue, adher-

years between pri-

ent in its entire extent to

mary and secondary

chest wall. Left lung nor-

growth, and for its

mal

recurrence as a mas-
sive tumor involving
whole of right lung

Scant,

Large cancer at tracheal

No details

Not given

Course of disease

rusty,

bifurcation extending into

remarkably rapid

later pu-

right lung, adherent to pos-

rulent,

terior wall of pericardium

abun-

and extending through into

dant.

both auricles. Right vagus

often

imbedded in tumor

bloody

316

TABLE IV

CotrVELAIBB,

Annales de gynec. et
d'obst., LX, 1903
DegSnerescence Ky-
stique congSnitale du
Poumon, etc.

De Gueldre,

Annal. de la Soc. de

Med. d'Anvers, LXII,

1900, 83-89
Cancer generalise du

deux Poximons

6 days

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

behind. Some dulness on left side
anteriorly. On right side anteriorly
below: diminished expiration, distant
bronchial breathing. Increasing dysp-
noea and aphonia; swelling over right
vocal cord. Death on 23d day after
admission

Parents normal health; good family
history, uneventful normal pregnancy,
normal birth. After birth, child cried,
breathed, and behaved like normal
child. On 5th day respiration became
short and rapid; cyanosis set in; child
refused breast and 6 days after birth
died. No precise diagnosis was pos-
sible

Always in robust health. Several
months before admission marked ema-
ciation. Cavity at right apex; slight
temperature ; intelligence slightly
clouded. Tympanitic note right apex
below clavicle; diminished respiration
and amphoric breathing corresponding
to tympanitic note. Tympanitic note
at both bases. Short cough. Clinical

MISCELLANEOUS

317

SPUTUM

AUTOPSY NOTES

METASTASES

MICEOSCOPE

BEMABKB

None

Middle lobe of right lung
connected with an enormous
cystic mass causing com-
pression and atelectasis of
upper and lower right lobes.
Hypertrophy of right ven-
tricle of heart. Cysts irreg-
ular in dimension

No details

Cyst-ade-
nomatous
structure.
Cuboid and
cylindrical
epithelium
with base-
ment mem-
brane with
irregular
nuclei near
base. Where
normal lob-
ules of pul-
monary tis-
sue exist they
are complete-
ly atelectatic.
The bron-
chial ramifi-
cations are
represented
by irregular
canals of
varying cali-
bre and ex-
tremely
simple struc-
ture out of
which de-
velop the
adenomatous
tubules. The
only sugges-
tion of intra-
lobular bron-
chial differen-
tiation are
patches of _
cartilage im-
bedded in
connective
tissue in the
vicinity of
the pulmo-
nary vessels

Abundant,

Retroperitoneal tumor

Mentioned

No details

Author goes into

mucopu-

size of child's head from

under

details as to how all

rulent

lumbar lymph nodes. Nut-
meg liver, numerous nod-
ules, larger and smaller;
nodules of spleen; 2 nodules
replace left testicle. Both

autopsy

the symptoms point-
ing to tumor of the
lung were wanting —
the slight cough, no
characteristic spu-

lungs completely filled with

turn, no dyspnoea, no

nodules. Diaphragm per-

pain, no dilatation of

318

TABLE IV

DiONISI,

Arch, di biol., Firenze
LVII, 1903, p. 716
SuUe degenerazione po-
licistica dei polmoni

Ehlich,

Primares Carcinom
an der Bifurcation
der Trachea

Monatschr. f. Ohrenhlk.,
1896, No. 3, p. 121
(Klinik v. Schrotter)

Kraus, Joseph,
Diss. Bonn, 1893

Ein Fall von ausgedehn-
tern links-seitigen
Pleuratumor

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

diagnosis: tuberculosis. Enormous
liver also taken as phthisical symptom.
No fever. Emaciation continues not-
withstanding improved appetite. Mili-
ary tuberculosis is thought of, but lack
of fever speaks against it. Two days
before death tumor as large as a fist
and painless, is recognized in left flank.
Death one month after admission

For some time cough, dyspnoea, slight
cyanosis, occasional night sweats. End
of December, 1902, fever, dyspnoea,
pain about right breast. Dulness be-
low right spine of scapula; harsh
breathing and crepitant rales. Tem-
perature up to 39.1. This state con-
tinued until January 5 with rapid de-
crease of temperature and signs of
heart failure. Death

No heredity; no serious illness. For
2 years cough and hoarseness at times.
General health good. Later slight
dyspnoea on exertion, dysphagia, dul-
ness at right apex. Laryngoscope
shows tumor obstructing both right and
left bronchus. Intense dyspnoea; pneu-
monia of left lower lobe. Attempt at
suicide by stabbing in chest; death

No heredity. Three years previ-
ous to admission, left pleurisy; well
after 2 months. Since then occasional
pain in left chest, though working.
For some months constant pain in left
lower chest, cough, increasing dysp-
noea, trigeminal neuralgia. Dulness
left upper lobe; absence of fremitus
and breathing. Some areas of bron-
chial breathing posteriorly. Heart
displaced towards right; loud systolic
murmur at base. No pulsation in
jugular notch. Left jugular more
full than right. Probatory puncture
yields only a few drops of bloody
serum. Increasing pain in left axilla.
CEdcema of upper left arm. Paralysis
of left vocal cord. Percussion of chest
becomes very painful. Right pupil
larger than left. Clinical diagnosis:

MISCELLANEOUS

319

Rusty

Mucoid, at
times
bloody.
No tuber-
cle bacilli
no tumor
elements

Mucoid,
more or
less abun-
dant,
never
bloody

AUTOPSY NOTES

f orated both sides by tumor
From history taken only
after death of the patient
it appears that primary tu
mor of the testicle was oper-
ated some years previous

Fibrinous pleurisy on
right side ; acute bronchitis.
Left pleura thickened. On
section of right lung a sys
tem of numerous cavities of
varying size and alveolar as-
pect decreasing in size and
number from above down-
ward. In lower lobe very
firm alveolar appearance,
resembling thyroid gland.
In apex of left lung similar
system of cavities. Genuine
lung tissue was firm with
increased consistency like
brown induration

Scirrhus at trachea at
bifurcation extending di-
rectly into both bronchi.
Cancerous infiltration of
oesophagus

Bulging of left chest :_
stomach enormously dis-
tended, reaching almost to
symphysis. Heart beyond
right mammillary line.
Clear serum in pericardium.
Grayish red tumor masses
fill whole of left pleural cav-
ity. Right lung displaced
downward. Tumor masses
between spine and pericar-
dium. The tumor fluctu-
ates at apex ; lower portion
grayish atheromatous mas-
ses with numerous hairs,
cartilage, and bone. (Der-
moid cyst of mediastinum)

METASTASES

No details

None.
Not even in
adjoining
lymph
nodes

Right
pleura

MICKOSCOPE

Areas of
emphysema-
tous lung tis-
sue ; also
areas where
the lung tis-
sue is re-
placed by
tubular
structure, the
tubules lined
with epithe-
lium mostly
in single lay-
ers and cylin-
drical ; other
tubules sug
gest acinous
structure ;
others filled
with exudate
and leuco-
cytes

Not given

Grajdsh
red tumor is
spindle cell
sarcoma

veins, no bloody ef-
fusion in pleura, no
lymph nodes

According to the
author this is not a
true neoplasm, but
a congenital cystic
process depending
upon the arrest or dis-
turbance of the proc-
ess of development

320

TABLE IV

Klemm,

..Diss. Munchen, 1905

tjber ein primares En-

dotheliom der Lunge

Labb:6,

Gaz.des Mai. infantile

etc., et d'obstet.

Paris, 1909. No, 15,

p. 113
Kyste hydatique

pulmonaire chez une

fillette de 8 ans.

Vomique, Guerison

Las^qtje,

Arch. Gen. de Med.,
1874,_ Vol. I, p. 486

Pleuresie droite deve-
lopp6e sous I'influence
d'un Lymphosar-
come en voie de
generalisation

LUNG IN-
VOLVED

Both

CLINICAL SYMPTOMS

tumor in chest probably not carcinoma
on account of scanty and not bloody
sputum. Bulging of left chest; left
jugular vein becomes hard. CEdcemaof
left leg. Increasing dyspnoea. Much
albumin in urine. Admitted Aug. 23,
1892; died November 11

Extreme dyspnoea. No lesions could
be detected in lungs or heart to ex-
plain dyspnoea. Repeated examina-
tions with bronchoscope negative.
Patient died of suffocation on day of
admission to hospital

Cough and bronchitis for a long
time. First seen February, 1907.
Since August, 1906, intermittent
cough with febrile attacks and sweat-
ing. Some scant hcemoptyses. Dif-
fuse bronchitis and gastro-intestinal
symptoms. Diagnosis of intestinal
grippe is made. Beginning of May,
breath becomes foetid. X-ray shows
shadow of upper | of left lung with
sharp border. Dulness below clavicle;
bronchial respiration; mucous rales;
absence of fremitus. Pleuro-pneumonia
is diagnosed and puncture is made
posteriorly (!), but only a few drops
of clear serum withdrawn. 32 hours
thereafter violent pain in left chest; no
fever. Suddenly vomited large quan-
tities of pus, white, thick, and foetid,
containing particles that look Uke
membrane. Some purulent and
bloody mucus is expectorated. After
this gradual diminution of aU symp-
toms. Physical signs in left chest
gradually disappear and improvement
is followed step by step by radiograph.
September, 1907, the healing is com-
plete except some signs of cavity below
left clavicle

Six weeks before admission pain in
right chest with slight chill, fever and
dyspnoea gradually increasing. Dul-
ness from angle of scapula downward.
Bronchial breathing above, dimin-
ished breathing over middle \ and
absence of breathing at base. Dul-
js from mammilla downward an-
teriorly, also with absence of breath-
ing. Liver enlarged. Later renewed
chill and next day exudate filled entire
right chest. Profuse sweats, anorexia.

MISCELLANEOUS

321

AT7TOPST NOTES

METASTASES MICROSCOPE

Sanguinolent serum in
both pleurse. Almost entire
left lobe consists of very firm
and dense tissue containing
no air except a thin periph-
eral layer. Fibrous prolif-
eration along bronchi.
Everywhere conglomera-
tions of miliary nodules.
Lower lobe of right lung in
same condition as left. Up-
per lobe numerous, often
confluent miliary nodules

Bronchial,

tracheal,
and medias-
tinal lymph
nodes

Yellowish, purulent fluid
in right chest; right lung
completely filled with puru
lent serum. Right bron-
chus compressed by en-
larged bronchial glands,
hard, yellow, and cheesy on
section. Nodules in left
lung. Numerous nodules in
liver up to size of small
apple. In both lungs along
the larger and smaller bron-

Gastro-
hepatic
lymph
nodes; nu-
merous nod-
ules in duo-
denum

Firm, fi-
brous tissue
mostly in a
state of hya-
line degenera-
tion. Nod
ules consist of
very small
fusiform cells
surrounded
by giant cells
No tubercle
bacilli

Examination
of vomitus:
portion of
membrane,
non-charac-
teristic bac-
teria and one
unmistakable
hook

Nodules
composed of
leucocytes,
well devel-
oped embryo
nal cells, and
less numerous
spindle cells

Probably sarcoma

Primary focus not
to be determined;
possibly in lung

322

TABLE IV

13 Lesieue et Rome,

Lvons Med., CXIII,
July, 1909, p. 74
Cancer massif du Pou-:
mon, secondaire a un
Cancer latent du Hec
turn

LShleix,

Verhand. der Deutsch,

Path. Gesellschaft,

1908, p. Ill
Cystisch papillarer

Lungentumor

Ogle, Ctril,

Trans. London Path.
Soc. Vol. XL VIII.,
1897, p. 37

16 RrniscH & Sch??vahtz
Mt. Sinai Hosp. Re-
ports, 1903, p. 26
Primary Sarcoma of the
Lung and Pleura

Lns'G IN-
VOLVED

CLINICAL SYMPTOMS

cfidoema'of abdominal waU, some ascites.
Puncture vdthdrew bloody serum and
patient felt better, but physical signs
remained the same. Liver becomes
larger. Increasing dyspnoea; icterus.
Death 4 weeks after admission. Du-
ration about 2 months

Cough for years; for IJ years loss
of flesh and strength. 3 months before
entering hospital ceases work. On ex-
amination nothing found except dulness
left base, diminished breathing, some
mucous rales. Continued loss of weight,
but nothing found to explain condition
except the few signs on lungs. Noth-
ing could be felt in rectum. Died 4
months after admission. During all
this time the only lung sjTnptoms
were pain in left chest, dyspnoea, and
persistent cough. Vocal fremitus
preserved. X-raj' showed extensive
shadow at left base and immobility of
left diaphragm

Died of tubercular pericarditis

Cough and occasional haemoptysis
for 5 years intermittently. Physical
signs suggest empyema ; hectic tj-pe of
fever. Death from profuse haemop-
tysia

Xo heredity. Sj-philis. Pain, loss
of weight, hoarseness. Bulging of
left chest. Dilated veins of upper ex-
tremities and chest. Flatness and
absence of voice and breathing. As-
piration negative. Enlargement of
IjTnph nodes, liver and spleen. CEdcema
of face, left arm and chest. Increas-
ing dyspnoea, fever up to 104, emacia-
tion

MISCELLANEOUS

323

SPTTTtrU

AUTOPSY NOTES

METASTASES

MICROSCOPE

REMAEKS

chi and scattered under

pleura similar nodular foci

At times

Massive tumor occupying

In liver and

Tumor of

Only example of

sanguin-

nearly all of left lower lobe,

under dia-

lung consists

large massive second-

olent, no

only a very small strip of phragm. All

of typical cy-

ary lung tumor. Au-

tubercle

lung tissue persisting at

other organs

lindrical

thor justly says that

bacilli.

base. Tumor broken down

healthy

celled carci-

if autopsy had not

Mostly

in places gives impression of

noma exactly

been so carefully

muco-

primary tumor in lung. In

hke that of

done, this case would

purulent

rectal ampulla 6 cm from

recttoiQ

undoubtedly have

and

anus a carcinomatous ulcer

been classified as

scant.

evidently primary

primary lung tumor.

Haemop-

It is also remarkable

tysis at

that there were prac-

various

tically no symptoms

times

of the rectal carci-
noma

No details

_ Besides the tubercular le-

No details

PapUlary

Origin possibly

sions there was found a tu-

and cystic

from bronchial mu-

mor the size of an apple in

adenoma

cous glands

lower lobe containing cav-

ities filled with mucus;

strands and ramifying tracts

of spongy tissue between

them

Profuse

Cavity in lower lobe sur-

No details

The tongue-

Origin probably in

haemop-

rounded mainly by lung tis-

like projec-

mediastinum com-

tysis.

sue communicates with left

tions have

pressing bronchus.

Offensive

main bronchus — evidently

stratified epi-

causing bronchiecta-

sputum

a bronchiectatic cavity —

thelium cov-

tic cavity, and pene-

suggested

offensive dark red contents.

ering fatty

trating and growing

bronchi-

Pear-shaped flat masses of

and fibrous

in this

ectatic

tissue roughly resembling

tissue and

dilata-

skin and covered _with hair

having many

tion

protrude into this cavity.
Several stalks are joined in-
to one mass which can be
traced beyond the ca'V'ity in-
to the mediastinum to right
of pericardial sac. Sac con-
tains sebaceous matter,
hairs 1 J inches long, and one
large tooth

sebaceous
glands

No details

Entire left chest and medi-

Retro-

Simply

astinum filled with tumor.

peritoneal

stated that

Heart dislocated to right.

lymph

tumor is en-

Large abscess in tumor con-

nodes

dothelioma

taining putrid pus

324

TABLE IV

SOMMERS,

N. Y. Med. Record,
LX, 1901, p. 475
Dermoid Tumor of the
Lung

SORMANI,

Gazz. d. Osp., Milano,
1890, XI, p. 314-322
Di un Caso di Cisti Der-
moids del Polmone
sinistro

LUNG IN-
VOLVED

REMARKS

Died of chronic pulmonary phthisis.
Both lungs tubercular and cavernous

No heredity. Was first child; preg-
nancy and birth normal. As baby
during first 4 months very susceptible
to cold and exposure to open air.
After lengthy nursing had to be held
in upright position, as she was seized
with strong attack of coughing and
dyspnoea. Cough increased as she
grew older; also dyspnoea; cyanosis of
lips. In her 16th year hairs were no-
ticed in her usually mucoid sputum;
they were supposed to have been in
food eaten and no further attention
was paid to them. Some time later a
whorl of black hair was expectorated.
Phthisical habitus. Harassing cough
and dyspnoea increased. Last two
years of Uf e in bed ; the slightest move-
ment, even turning, caused severe pain
in chest and excessive dyspnoea. Could
not eat for dyspnoea. Would not seek
medical aid, saying there was no cure
for a poor consumptive. Admitted to
hospital July 17, 1887. Exact exami-
nation could not be made on account
of moribund condition of the patient.
Death several hours after admission

MISCELLANEOUS

325

No details

Mucoid,
hairs

AUTOPSY NOTES

Besides the tubercular
condition a cystic body was
found at apex of right lung
containing large masses of
hair and some "dentoid
bodies"

Left pleura adherent. On
section of left lung yellowish
gray creamy atheromatous
material of nauseating odor
and containing small brown
hairs. Nearly the entire
upper lobe and f of lower
converted into a large pouch
the size of a new-born child's
head, containing the ather-
omatous material. The wall
of the cavity is firm and
hard and does not communi-
cate with a bronchus. There
are many places covered
with longer or shorter brown
hair. In some places it re-
sembles cutis covered with
hair; there are also small
spots resembhng cartilage.
There is a small cyst size of
a nut above hUus, also a
large one having the same
structiu'e and characteris-
tics except that the hair is
black. Right lung normal.
Turbid serum in right pleura
and pericardium

METASTASES

No details

MICEOSCOPE

No details

Wall of sac
resembles
cutis in
structure
with typical
papillEe,
hairs, epi-
thelium,
sebaceous
glands, etc.

PLATES

Plate

■ 0^ *T-*': ■

Plate

Plate III

Plate IV

Plate V

Plate VI

Plate Vil

Plate VIII

Plate IX

^S^

"'=^' ''^

Plate XI

Plate XII

Plate XIV

Plate XV

Plate XVI

»iaRBP.sfi»,(. -77,' . -»■ ^

COLUMBIA UNIVERSITY LIBRARY

This book is due on the date indicated below, or at the
expiration of a definite period after the date of borrowing,
as provided by the rules of the Library or by special ar-
rangement with the Librarian in charge.

DATE BORROWED,,

u °^m^

DATE BORROWED

DATE DUE

<J'

jL S 80****-

jclul^'}

C2e(2S0)M100

^^COgLUMB.A«,TV LIBRARIES ,hs,,s,x)

2002281376

PD667

Ad5 !

Adler
Primary malignant growths of th^,

Internet Archive Audio

Featured

Top

Images

Featured

Top

Software

Featured

Top

Texts

Featured

Top

Video

Featured

Top

Mobile Apps

Browser Extensions

Archive-It Subscription

Save Page Now

Full text of "Primary malignant growths of the lungs and bronchi; a pathological and clinical study"

See other formats